T 1 3  2 1     Tr  aclieo  -  Bronclioscopy, 
190^  Esopliagoscopy  and 


rjbevalier  Jackson^  M.D* 


-I'll—l'^Wl 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


./ 


Tracheo-Bronchoscopy, 

Esopnagoscopy  and 

Gastroscopy. 


BY 

CHEVALIER  JACKSON,  M.  D. 

Laryngologist  to  the   Western   Pennsylvania   Hospital,   tlie   Eye   and 
Ear   Hospital,  and  the  Montefiore   Hospital. 


WITH  FIVE  COLORED  PLATES  AND  MANY 
ILLUSTRATIONS. 


ST.  LOUIS,  MO.: 

THE  LARYNGOSCOPE  COMPANY. 

1907. 


COPYRIGTED    1907 

BY  Chevalier  Jackson. 


TO    THIC 

Father  of  Bronchoscopv, 

Professor  Gustav  Killiax, 

as  a  token  of  esteem, 

this  book  is  dedicated. 


\^ 


6242S7 


Bicnedieal 
Library 

(^07 


Preface. 

The  )«ime  has  L-ome  when  not  onlv  the  profession  hnl  also  the  pubnc 
demands  tliat  every  Iar\-ngologist  shall  be  expert  at  the  removal  of  for- 
eign bodies  from  the  trachea,  bron:iii,  esophagus  and  stomach.  The  day 
has  come  when  the  treatment  of  diseased  organs,  especially  chronically 
diseased  organs,  without  looking  at  them  is  regarded  as  a  groping  in  the. 
dark  that  i^  pennissible  onl\-  in  organs  that  cannot  be  safely  examined. 

The  eso|)hagus  has  lieen  for  some  years  granted,  though  somewhat 
grudgingly,  a  place  among  the  organs  to  be  examined.  The  trachea  and 
l>ronchi,  owing  to  the  initiative  of  Professor  Gustav  Killian,  have  been 
recently  accorded  a  place  also.  Lastly  it  has  been  the  author's  privilege  to 
demonstrate  the  ease  with  which  the  stomach  may  be  examined  by 
endoscopy. 

At  the  present  time,  the  only  available  information  in  the  English 
language  on  these  subjects  is  the  reports  of  cases  scattered  through  the 
journals.  These  reports  do  not  give  working  data  li\'  which  the  student 
mav  learn  how  to  proceed.  This  book  is  intended  to  furnish  this  informa- 
tion, and  is  not  in  any  sense  exhaustive.  It  is  preliminary  to  a  complete 
work,  which  the  author  has  in  preparation. 

While  the  author  realizes  that  there  are  men  more  capable  of  writing 
on  the  subjects,  yet.  as  they  have  not  done  so,  this  little  book  is  offered 
with  a  full  realization  of  its  shortcomings,  but  also  with  the  assurance 
that  every  assertion  therein,  not  attributed  to  someone  else,  is  the  result 
of  practical  experience. 

Thanks  are  due  to  Dr.  Jnhn  W".  Boyce  and  Dr.  Ellen  J.  I'attersoii 
for  aid. 

Chev.\lier  J.\cksox. 

Pittsburgh.  Pa..  ]\larch.  1907. 


Introduction. 

P.\-  direct  larvnn;oscopy  is  meant  the  direct  examination  of  the  interior 
of  the  larynx,  in  contradistinction  to  indirect  laryngoscopy  by  which  a 
reflected  image  of  the  larvnx  is  examined.  Direct  laryngoscopy  is  prac- 
ticed with  the  aid  of  various  instruments  which  serve  to  drag  out  of  the 
way  the  anatomical  structures  which  ordinarily  obstruct  the  view. 

By  tracheo-bronchoscopy  is  meant  the  inspection  of  the  interior  of  the 
trachea  and  bronchi  with  the  aid  of  tubes  which  serve  as  specula,  bring- 
ing into  view  successively  the  various  passages,  by  pushing  aside  struct- 
ures that  would  obstruct  the  view,  or  dragging  the  passages  into  a  new 
position  where  they  will  be  in  the  direct  line  of  vision. 

^^'llen  the  tiilies  are  introduced  through  the  natural  passages,  the 
procedure  is  spoken  of  as  upper  tracheo-bronchoscopy,  as  distinguished 
from  lower  tracheo-bronchoscopy  in  which  the  tubes  are  passed  through 
a  tracheotomy  wound. 

By  esophn.goscopy  is  meant  the  inspection  of  the  interior  of  the  esoph- 
agus with  the  aid  of  long  tubes  which  serve  as  specula.  It  is  almost  al- 
ways practiced  through  the  natural  passages. 

By  gastroscopv  is  meant  the  inspection  of  the  interior  of  the  stomach 
by  means  of  tubes  wdiich  serve  as  specula.  It  is  usually  practiced  through 
the  natural  passages,  though  it  is  occasionally  done  through  an  abdominal 
wound  or  fistula. 


Contents 

Part  I. 
tuaciii-:ii-i:ronchoscoi*y. 

Chapter  I.     Historical  Xdtes. 

Cliapter  II.     Jnstruniciits. 

Chapter  III.     Acquiring  Skill. 

Chapter  I\'.     Technic. 

Chapter  \'.     Direct  Laryngoscopy. 

Chapter  \1.     Anatomy  of  the  Tracheo-bronichial  Tree,  Topographi- 

cally. Radiographically  and  Endoscopicallv  Consid- 
ered. 

Chapter  ATI.  Tracheo-briinchiiscoi)y  in  Diseases  of  the  Trachea  and 
Bronchi. 

Chapter  A  III.  Tracheo-bronchoscopy  Upper  and  Lower,  for  the  Di- 
agnosis and  Extraction  of  Foreign  Ilodies. 

Part  II. 

ESOPHAGOSCOrV. 

lntr(  iduction. 

.\natomical  Notes  on  the  Esophagus. 

Xormal  Esophagoscopic  Appearances. 

Technic  of  Esophagoscopy. 

Diseases  and  Anomalies  of  the  Esophagus. 

Stenotic  Diseases  of  the  Esophagus. 

Acute  Inflammations. 

Cicatricial  Stenoses. 

Neoplastic  Stenoses. 

Spastic  Stenoses. 

Compression  Stenoses. 
Chapter         XV.     Non-Stenotic  Diseases  of  the  Esophagus. 

Diverticula. 

Diffuse  Dilatations. 


Chapter 

IX. 

Chapter 

X. 

Chapter 

XL 

Qiapter 

NIL 

Chapter 

XIII. 

Chapter 

XIV. 

COXTEXTS— Continued. 

Tntlanmiations  and  Ulceration?. 
Paralyses  and  Pareses. 
Neuroses. 
Chapter       XVI.     Foreign  Bodies  in  the  Esophagus. 

Part  III. 

GASTROSCOPY. 

Chapter     X\'II.  History. 

Chapter   X\'III.  Usefulness  of  Gastroscopy. 

Chapter       XIX.  Instruments  for  Gastroscopy. 

Chapter        XX.  Technic  of  Gastroscopy. 

Chapter       XXI.  Area  of  the  Stomach  Explorable  by  Gastroscopy. 

Chapter     XXII.  Difikulties,  Dangers  and  Contraindications. 

Giapter   XXIII.  Gastroscopic  Appearances. 


Part  I 


CHAPTER  I. 
Historical  Notes. 

Bozini  in  1807  examined  the  npper  end  of  the  esophagus. 

\'oltolini  and  Waldenberg,  in  i860,  and  Stocrck,  in  1861,  devised 
esophageal  spccida  iisini;-  the  laryngeal  mirror. 

Kussmaul,  in  1868,  did  the  first  esophagoscopy  worthy  of  the  name, 
using  a  Desormeaux  urethroscope  elongated  to  43  cm.  He  diagnosticated 
a  carcinoma  of  the  thoracic  esophagus  and  approache<l  the  cardia.  His 
tube  was  rigid  and  he  used  the  "sword  swallowing"  position. 

Trouve,  in  1873,  designed  a  "polyscope"  consisting  of  a  tube  having 
a  window,  and  titted  with  prisms  and  lenses  constituting  an  optical  aiipa- 
ratus.     This  was  used  by  Ledentu  and  Raynaud  for  esophagoscopy. 

Alikulicz,  in  1881,  with  the  aid  of  Mr.  Leiter, -designed  an  esopha- 
goscope  consisting  of  a  tube  into  which  an  optic  apparatus  was  slid  after 
the  removal  of  the  mandrin  used  to  facilitate  introduction  of  the  tube  into 
the  esophagus.  He  also  examined  the  stomach  with  an  elongated  form 
of  his  esophagoscope  by  adding  an  angle  and  an  additional  prism. 

Gottstein,  in  1891,  advocated  esophagoscopy  under  cocain  anesthe- 
sia. Prior  work  having  been  all  done  under  either  general  anesthesia  or 
morphin  narcosis,  mostly  the  latter. 

Von  Acker,  in  icjo2,  reported  the  tirst  cases  of  tracheoscopy  worthy 
of  the  name. 

Mikulicz,  in  i8y6,  reported  successful  cases  of  tracheoscopy. 

Kirstein,  in  1897,  described  tracheoscopy  as  well  as  his  now  well 
known  direct  laryngoscojiy.  For  the  latter  he  used  at  tirst  a  tubular 
spatula. 

Killian,  in  1897,  removed  a  foreign  body  from  a  bronchus  and  dem- 
onstrated the  feasibility  of  upper  bronchoscopy.  Later  he  developed 
lower  bronchoscopy.     These  were  the  greatest  steps  in  endoscopy. 

Coolidge,  in  1899,  reported  the  removal  of  a  fragment  of  a  trache- 
otom\-  canula  from  the  right  bronchus  of  a  man. 

\'.  .Schrotter  and  Piniazek,  in  1901,  reported  some  excellent  work  in 
lower  tracheoscop}-  and  hronchosco]iy. 


14  HISTORIC.  I L  XOTES. 

Einhiirn.  in  uj02,  devised  an  esiiphagosco])e  having  an  auxiliary  tube 
made  in  the  wall  of  the  main  tube.  In  the  auxiliary  tube  was  inserted  a 
light  carrier  wliieh  served  as  a  double  conducting  wire  to  carry  current  tn 
the  electric  lamp  which  it  carried  to  the  distal  end  of  the  tube. 

Guisez.  in  1903.  removed  a  nail  from  a  tertiary  bronchus. 

Ingals,  in  1904.  used  a  separate  light  carrier  in  a  Killian  tube  ami 
removed  a  pin  from  a  bronchus  of  a  woman. 

Chevalier  Jackson,  in  1904.  combined  the  lighting  principle  of  the 
Einhorn  esojihagoscope  with  the  tube  of  Killian.  and  in  1905  he  designed 
a  bronchoscope  in  which,  in  addition  to  the  auxiliary  canal,  a  drainage 
canal  was  placed.  In  1906  he  described  a  gastroscope  he  had  devised  and 
reported  a  series  of  14  cases  in  which  he  had  obtained  results  of  value 
from  gastroscopv.  including  12  cases  with  lesions,  one  in  which  a  lesion 
could  be  positively  excluded  and  one  case  of  extraction  of  a  foreign  body 
from  the  stomach. 

TTie  foregoing  is  not  by  any  means  a  complete  review  of  the  history 
of  the  subject.  Only  a  few  of  the  more  notable  events  are  given.  The 
reader  interested  in  the  history  is  referred  to  the  almost  complete  bil)- 
Jiography  appended. 


CHAPTER    II. 
Instruments. 

The  instruments  in  use  t.vilay  for  tracheo-bronchoscopy  and  esopha- 
goscopy  may  be  divided  into  two  classes :  •  ,  •  , 

I  Those  without  hghting  apparatus,  consistmg  of  a  tube  mto  whicli 
hcrht  is  projected  irom  an  independent  source  of  hght,  usually  a  head 
lamp  These  instruments  are  simple  and  very  satisfactory  for  short  tubes. 
For  very  long  tubes  great  skill  and  much  practice  are  required,  and  be- 
yond 50' cm.  they  are  impracticable  on  account  of  the  loss  of  light  through 
distance,  bubbles  of  secretion,  etcetera.  The  object,  be  it  normal,  path- 
ologic or  foreign  substance,  is  too  feebly  illuminated  to  throw  back  a 
strong  image.  All  of  these  disadvantages  are  overcome  by  great  skill. 
Killian  and  von  Schrotter,  who  have  clone  the  greatest  amount  of  upper 
bronchoscopic  work,  which  requires  long  tubes  of  small  diameter,  use  this 

form  of  tube. 

2.  In  the  other  class  of  instruments  the  light  is  at  the  distal  extrem- 
ity o7  the  tube  where  its  full  power  is  available  practically  without  loss 
through  distance,  and  where  its  obliquity  renders  visible  otherwise  unob- 
servable  details.  Einhorn  atid  Glucksman  have  used  this  form  for  the 
esophagus,  and  the  author  has  perfected  a  bronchoscope  and  a  gastro- 
scope  which  utilize  the  great  advantages  of  this  plan  of  illumination. 

INDEPENDEXT   ILI.UM  IX.^TORS. 

KirstcinS  headlamp  (Fig.  i)  is  the  most  used  form.  It  consists 
practically  of  a  combination  of  a  Wendell  C.  Phillips  electric  headlight 
and  a  miniature  form  of  the  ordinary  forehead  mirror.  The  parallel  rays 
emerging  from  the  lens  instead  of  being  projected  directly  toward  the 
objec't  are  caught  upon  a  small  mirror  set  at  45°  which  reflects  the  rays 
parallel  with  the  line  of  vision  of  the  observer's  eye,  the  mirror  having  a 
small  aperture  which  is  placed  in  front  of  the  pupil. 

The  headlight  of  Giiisec  (Fig.  2),  consists  essentially  of  three  Phil- 
lips headlights  clustered  around  the  visual  aperture  of  the  disc  on  whicR 


]6 


ILLVMIXATORS. 


they  arc  mounted,  the  axes  of  the  lamps  converging  slightly.  The  liglit 
from  this  apparatus  is  excellent,  the  heat  very  slight,  and  annoying  ran- 
dom rays  are  absent.  There  is  a  disc  to  obstruct  the  view  of  the  left  eye, 
useful  for  those  unaccustomed  to  ignore  the  image  of  the  left  eye  while 
using  the  riHit. 


Fig.  1 — Kirstein's  headlamii  ami   autosfoiie. 


The  clcctroscol'C  of  Cnspcr  is  virtually  a  handlamp  form  of  its  suc- 
cessor. Kirstein"s  headlamp,  a  prism  occupying  the  place  of  the  mirror. 
Half  of  the  orifice  of  the  tube  is  occluded  by  the  cap  of  the  lamp,  thus  in- 
terfering with  instrumentation  :  but  for  demonstration  and  for  the  intro- 
duction of  unilluminated  tubes  which  are  to  be  used  later  with  the  head- 
lamp, it  is  useful. 


TUBIiS. 


TrUKS. 


Kirstcin  used  orisjinally  a  tulnilar  spatula  attacliod  to  a  Casper's 
handlamp  for  direct  laryugoscopy.  but  afterward  abandoucd  the  tulndar 
form  for  an  open  spatula  with  a  hood  at  the  proximal  end. 

Killian    uses    the    tubular    fnnii    (  l-'itr-    3)    "'itli    the    Kirstcin    head- 


Flti.  i. — Killiau'!!  split  tubular  siialula. 


18 


SPECULA. 


light.  He  has  designed  a  most  ingenious  spHt  tube  spatula  (Fig.  4) 
to  facilitate  the  introduction  of  tubes  into  the  trachea,  the  two  halves  of 
the  split  spatula  being  separated  for  removal  of  the  spatula  after  the  ilistal 
end  of  the  bronchoscope  has  passed  the  glottis.  Six  tubular  spatulse, 
3  sizes  solid  and  3  split,  are  listed  by  the  manufacturer,  F.  L.  Fischer, 
Freiburg  im  Breisgau. 

Alosher  has  devised  a  most  ingenious  speculum   (Fig.  5)   for  work 


^ 


Fic.  5. — Mosher"s  esophageal   speculuui   aail   iiistriiraouts   for   llie  surgery   of  the 
upper  end  of  Uie  esophagus. 


srr.crL.L 


19 


about  tlic  upper  cuil  of  the  esnplKiL^us.  U  is  used  witli  the  Kirstein  or 
Phillips  headhght.  or  even  w  itli  the  forehead  niirrnr,  if  for  any  reason  this 
should  be  necessary. 

The  autb.or  uses  a  self-illuniinatiuii'  tubular  s]K-euluni  (Fig.  (>)  hav- 
ing a  drainage  tube  made  in  its  wall  which  maintains  the  lield  of  observa- 
tion, clean  and  free  from  secretion,  and  prevents  the  necessity  for  interrup- 


I''lG.   7. — AiiUior's  separable  speculum   for  passing  tironchoscopes. 
Handle.  A  B.  is  onl.v  used  on  tlie  sitting  patient. 


tion  for  the  patient  to  expectorate,  the  constant  desire  to  do  which  is  the 
source  of  more  discomfort  to  the  patient  than  any  other  part  of  direct  lar- 
yngoscopy. For  the  introduction  of  tubes  he  uses  a  split  spatula  pat- 
terned after  the  ingenious  device  of  Killian.  but  having  it  separable  in  the 
other  direction,  so  as  to  avoid  wounding  the  mucosa.  (Fig.  7)  It  is  made 
in  two  forms,  one  is  self-illuminated,  the  other  is  not. 


20 


INSTRUMENTS 


Fig.    S. — .Mikulicz's    psophagosoope,  maudrin    aud     (ui'.\t    to    bottojii)     "practice 
liougio."     Tlic  liandle  portion  i.-.  a  Caspar  liandlamp. 


Fig.   0. — Rosenheim".s  esophagoscope.  mandrin   forceps  and   cotton   liolder. 


IXSTKL'MBXTS. 


■n 


1     U„rv-linped    hou.^ie.     li.  Tube   with    mandrin    in    place.     :'..   (  ottou    holdeu     4 
1.   lM)i.\  uppeci     )oi.„ii  i„i„rerl  curette      S,  !>.   li>.   H.   Fofceps  :a\vs. 

and  7.  Forceps.     5.  Forceps  handle.     (,.  .Jointed  curette.     ., 

12.  Leiter's  paneloctroscope  attached  to  luhe. 


10      II         12        '3       I" 


7  8  9  10       II 

I     il    ^0     ^R     ^^B 

^^^    ^^^    ^^n 


.••■jmwiiwt^**'^"*""^' 


forcep.  for  removal  of  specimens.     S.  Coiuaatel   toiop. 

10  to  IC.  Sounds  and  foreign  body  hooks.     1..  (ott.m  lu.ld.i. 


99 


TUBES. 


Mikiilic",  whose  work  is  mainly  esophageal,  uses  straight  metallic 
tubes,  the  distal  ends  of  which  are  cut  off  slantingly.  (Fig.  8.)  They 
are  fitted  with  a  mandrin  tipped  with  a  soft  rubber  pilot.  Tlie  inside  of 
the  tube  is  Ijlackened  to  prevent  annoying  roHections.  For  illumination 
he  uses  the  Casper  handlamp. 

Rosciihciiii  uses  a  similar  tube  and  illuminalnr.     (Fig.  9.) 
J'oii  Hacker  for  the  esophagus  uses  a  similar  tube  but  uses  the  Leiter 
panelectroscope,  a  half  open  cylindroid  box  with  mirrors.      (Fig.  10.) 


Fio    11'. — Killian"^;  bronclioscope  and    (below)    Kirstein's  esophagoscope   with   wiiuliiw. 

Starck's  esophageal  tubes,  shown  in  h'igure  11,  have  no  fitted  man- 
drin, a  form  of  esophageal  sound  being  used  as  a  pilot. 

Kil Han's  tubes  (Fig.  12)  are  designed  especially  for  the  trachea  and 
bronchi,  the  svstematic  exploration  of  which  dates  from  Killian"s  original 
demonstrations.  He  uses  straight  rigid  tubes  of  plated  copper,  graduated 
in  centimeters  outside,  and  highly  polished  inside.  They  all  fit  into  a  uni- 
versal handle.     (Fig.  13.)     The  sizes  of  Killian's  tubes  for  bronchoscopy 


Fig.  33. — Uuiversal  handle  to  fit  Killian's  tubes. 


to  be  had  in  the  shops  vary  from  7  to  9  mm.  in  diameter  and  14  to  52  cm. 
long.  For  esophagoscopy  the  sizes  are  from  ii  to  13  mm.  in  diameter, 
and  from  19  to  52  cm.  long.  Including  both  esophagoscopes  and  bron- 
choscopes 18  sizes  are  listed,  besides  the  6  tubular  spatulje.  All  of  these 
are  not  essential,  but  for  the  best  work  and  to  be  prepared  to  meet  all 
emergencies,  the  largest  possible  assortment  should  be  on  hand,  so  that 
the  tube  of  shortest  length  and  largest  diameter  possible  may  be  used,  for 
the  technical  difficidties  varv  inverseh'  to  the  size. 


TUBES. 


23 


Killian  uses  the  Kirsk'in  lK'a(ll:iiii|)  fur  ilkiminatidn.  X'on  SchrrittiT 
designed  a  bronchoscope  (Fig-.  14)  the  chief  advantage  of  which  is  that 
the  tubes  fit  in  a  universal  handle,  so  that  after  passing  a  second  tulje 
through  the  first,  the  handle  may  be  removed  fmm  the  first  and  attached 
to  the  second  and  thus  onl\  one  handle  is  in  use  at  a  time. 


Fig.  14. — von  Sohrijtter's  hrouclioscope. 
A.   Bi'oiiclioseii|iic    tube.     B.  Dotacliable   liantlle.    which    can    he    removed,    leaving 
onl.v  the  c.vlimlrical  part  of  tlie  tuhe  and  attaclied  to  a  second  tube  passed  throngh  tlie 
lirst. 

Einhorn's  esophagoscope  (Fig.  15)  consists  of  a  straight  tube  without 
lip  or  ring  or  thickening  at  the  distal  end.  In  the  wall  of  the  tube  is  made 
a  small  auxiliary  tube  in  which  a  light  carrier  is  inserted,  carrying  the 
light  to  the  distal  end  of  the  instrument.  A  mandrin  locked  by  a  pin  is 
fitted,  presenting  a  conical  end  for  insertion. 


Fii;.  1."). — Kiuhorn's  esophago.scope  and  mandrin. 


Ingals  uses  a  Killian  tube  in  which  he  inserts  a  little  lamp  on  a  light 
carrier  (Fig.  16),  removing  the  light  carrier  before  he  inserts  a  mop  or 
a  forceps.  Tlie  light  being  removed,  the  forceps  are  inserted,  and  the 
foreign  body  or  specimen  is  seized  by  the  sense  of  touch  and  the  memory 


24 


TUBUS. 


of  its  pDsitinii,  ilic  depth  (if  insertion  licinn;-  known  liv  liavin,^;-  a  provionsly 
placc(l  mark,  as  h\  a  niljljer  hand,  on  the  forceps  shank,  showing  the 
length  of  the  particular  tnbe  used. 

The  author's  tubes  (Fig.  17)  are  ilUiniinated  liy  a  small  "cold"  lamp 
carried  down  to  the  extremity  by  a  light  carrier.  The  chief  advantages 
of  this  form  of  illumination  are  these: 

I.  The  light  being  in  the  tube  is  always  illuminating  the  object,  re- 
.gardless  of  the  movements  of  patient  or  operati  ir. 

I'or  this  reason.  i)rolonged  practice,  as  with  the  headlamps  and  unil- 


J''i(;.  IG. — Ir.sals'  lirouehoscope. 
A.  Killiau  liilit.     B.  Iiii^als'  light  ciirrier. 


luminated  tulies.  is  not  necessary.  True,  the  lamp  occasionally  gets  smeared 
with  blood,  but  it  requires  no  more  time  to  withdraw  the  light  carrier  and 
clean  the  lamp  than  it  does  to  clean  off  the  mirror  or  lenses  of  a  head- 
lamp which  are  Ijcdaubed  every  tinue  the  patient  coughs,  and  when  thus 
bedaulx'd  the  light  is  dimmed.  The  constant  readjustment  of  a  headlamp 
consumes  nuich  time,  as  each  time  a  piece  of  sterile  gauze  nuist  be  picked 
up  to  handle  it  with  in  order  not  to  infect  the  hands. 

2.     There  is  no  urgent  need  of  selecting  the  shortest  ])Ossible  tube. 
Tlie  illumination  is  as  good  and  the  \'iew  as  good  through  an  80  cm.  gas- 


T" 


FUi.  17 


Author's  bruiichoscopc.  csoiiliagoscope  au<l  ga-stroscoye. 


troscope  as  through  a  tube  of  one-foiu-th  this  length.  For  this  reason, 
lower  tracheo-bronchoscopy,  with  the  necessity  of  tracheotomy,  is  less 
often  required. 

3.  A  great  advantage  is  the  obliquity  of  the  light,  due  to  the  location 
of  the  lamp  at  one  side  of  the  orifice  of  the  tube.  Every  photographer 
knows  that  light  from  back  of  the  camera  makes  a  flat  picture,  and  every 
opthalmologist  knows  that  details  of  corneal  lesions,  invisible  with  direct 
light,  show  up  plainly  with  oblique  illumination.  The  darker  shades  of 
red  do  not  throw  back  rays  strongly,  so  that  in  case  of  a  long  tube,  with 


.ICCnSSORV  IXSTRCMRXrS. 


2.-) 


llu-  liglit  at  onr  rnd  and  a  dark  ivd  nl)ji'ct  at  tlio  oilier,  the  liiilit  traveliiiL; 
twice  the  tiihal  length,  the  greatest  skill  and  the  utmost  perfection  dl  ev- 
ery detail  of  apparatus  are  absolutely  essential  for  results. 

4.  .-\  small  bubble  or  mass  of  secretion,  or  an  instrument  introduced 
into  the  tube  does  not  cut  off  any  light  as  the  light  is  beyond. 

These  points  make  it  possible  for  the  surgeon  to  do  good  work  with 
these  tubes  without  the  long  arduous  preliminary  jiractice  necessary  with 
the  headlight  and  uiullumiuated  tube,  though  these  have  other  ad\-an- 
tages  once  the  skill  is  acc|uired.  especiall\-  in  cases  where  large  and  short 
tubes  can  be  used.  Each  tube  is  fitted  with  its  own  handle  which  is  a 
great  saving  of  time,  as  compared  to  attaching  a  handle  e\er\  time  a  lube 
of  different  size  is  inserted. 

The  tubes  for  general  use  are  fitted  with  an  auxiliary  drainage  canal 
which  maintains  a  dr> ,  clean  condition  at  the  distal  end  oi  the  tube. 
Occasionallv  a  tube  is  needed  without  this  auxiliary  drainage,  but   oul\- 


l-'u..    LS. — Antlior's  secrftiou-:\s|iii;ilcir. 


rarely,  as  in  case  of  passing  a  narrow  stricture.  The  secretion  is  pumped 
out  by  the  negative  pressure  maintained  in  the  bottle  with  the  aspirating 
syringe  (Fig.  18),  the  rubber  tubing  connected  with  the  bottle  being 
slipped  over  the  outlet  of  tlie  drainage  canal.  Should  the  drainage  canal 
become  obstructed,  which  very  rarely  happens,  an  extra  drainage  tube  is 
run  in  and  out  as  needed,  being  connectable  to  the  same  asjiirator.  These 
extra  drainage  tubes  are  useful  for  blowing  in  medicaments  or  bismuth 
oxide  for  Roentgen  rav  localization,  b'or  bronchoscopy  drainage  is  not 
often  necessary. 

ACCKSSORV  INSTKCMENTS. 

Forccf^s.  The  forceps  of  Coolidge  (  Fig.  19)  are  exceedingly  satis- 
factory. The  tube  is  pushed  over  the  jaws  by  a  trigger  action  and  the 
large  handle  will  be  very  convenient  to  most  operators.  Starck's  forceps 
(Fig.  11)  are  actuated  by  pushing  a  thumb  Initton  and  are  good. 


26 


FORCEPS. 


Fig.  lU. — C'ooliilge's  forceps 


Fig.  20. — Killian's  toiveps  antl  manner  of  holding  it. 


Fio.  21. — Killian's  .stronger  forceps  anil  varions  .iaws,  tlie  threatled  one  being  an 
expanding  form  for  the  extraction  of  hollow  foreign  bodies. 


FORCIiPS.  2( 

Kalian's  forceps  (Fig.  20)  are  made  in  t\\  i  styles  of  mechanism  and 
Will  be  found  to  do  their'  work  ijerfectly.  The)  arc  excecdino-ly  conven- 
ient to  those  accnstomcd  to  the  tin,L;er-lever  aclinn  >>\  Dr.  .Mnrrcll  .Macken- 
zie.    A  stronger  pattern  is  shown  in  1-ig.  21. 


G:==C 


I-'K,.  2"-!. — Aiitlior's   forceps. 

The  author's  in-eference  is  for  tlie  light,  convenient,  ringed  handle 
(Fig.  22)  we  are  all  so  much  accustomed  to  manipulate  in  the  hemostat. 
The'tuhe  is  pushed  over  the  jaws,  the  jaws  are  n..t  drawn  into  the  tube. 


''■'>5!!^ 


r-'iG.  2o. — Author's  I'orci'iis,  oiu-vimI  .i,T\\> 


the 


thus  they  do  not  retreat   from  their  bite.     As   with  all  tube  torceps, 
strength  of  grip  of  this  instrument  is  astonishmg.     Different  lengths  of 
canuhe   and ''differently    formed   jaws   are   made   to   fit   one  handle.     The 


!''«:.  24.— Aiillior's  forrcps.  ciippiil  .jaws. 


form  shown  in  h'lgure  27,  is  for  going  down  alongside  a  |iin  or  ncedl.-  and 
grasping  it  sidewise,  or  reaching  around  a  turn  or  bend,  or  sidewise  past 
the  end  of  the  tube.  Tliese  are  also  made  with  cupped  extremities  like 
Fig.  24,  for  the  biting  out  of  a  specimen  laterally  from  a  wall.  Either  cup- 
ped or  serrated  they  will  b.'  found  exceedingly  useful  for  biting  off  a  pa- 


28 


ACCESSORY  IXSTRCMHXTS. 


jiillciiiia  or  other  neoj)lasin  from  the  anterior  commissure  of  the  larynx, 
and  similar  jnirposcs.  as  will  also  the  pimch  forceps  (Fig.  25). 

Cotton  carriers  with  roughened  ends  are  too  uncertain.  It  is  ainioy- 
ing  to  have  the  di>ssil  slip  off.  and  still  more  so  is  the  delay  occasionally 
necessary  for  a  prolonged  search  for  it.  Mikulicz  has  devised  a  very  in- 
genious claw  end  to  hold  the  cotton.     Coolidge  uses  the  most  comfortably 


i'J(j    U-j. — Author's  forceps,     rinicli  jaws  for  excision  of  a  speciun'ii.     U'lie   lower 
instrument  is  a  tent  carrier  to  work  in  forceps  liaudle. 

safe  device  (Fig.  26).     The  slip  collar  screws  down  on  the  spring  jaws 
so  that  thoy  cannot  lose  the  dossil. 

The  author  uses  these  exclusively  for  bronchoscopic  work,  though 
for  the  esophagus  and  stomach  where  there  is  no  risk  from,  or  delay  in 
removing,  the  lost  mop,  the  author  uses  the  simple  slide  which  does  not 
screw,  small  gauze  sponges  being  used  instead  of  cotton,  which  is  pront 


soiisa 


Fig.  iMj. — Coolidae's  cotton  lioliler. 


to  leave  threads  that  interfere  with  vision.  About  a  dozen  carriers  are 
needful  for  rajiid  work. 

( )f  the  other  accessory  instruments,  various  hooks,  probes,  etc.,  are 
useful. 

Alosher  has  devised  a  most  ingeniou.=  safety  pin  closer  (Fig.  2j).  It 
consists  of  a  ring  which  is  passed  clown  below  the  open  pin  ;  then  the  pin 


Flc.  27. — Moslier's  safet.v  |)iu  closer. 

is  pushed  in  spring-end  first  by  the  little  pronged  instrument.  To  facili- 
tate passing  the  ring  below  the  pin,  the  author  has  arranged  a  stem  that 
permits  of  introducing  the  instrument  with  the  ring  in  the  same  plane  as 
the  stem.  ,\fter  the  ring  has  passed  the  pin,  moving  the  handle  turns  the 
ring  to  a  right  angle  with  the  stem.      ( Fig.  28. ) 

For  endolarvngeal  surgerv,  such  as  the  incision  of  edematous  masses, 


Acciissni^y  ixsriu witixis. 


•29 


(lixisimi  of  stenotic  webs,  openinj;'  of  abscesses,  ami  similar  work  it  will 
be  found  necessary  to  bave  at  least  one  knife.      (Fitj.  29.) 

A  mouth  g-ag  is  a  most  important  accessory,     b'ergusou's   (Fig.  30) 
has   given   tbe  author  most    satisfaction.     .\   long  cleanins.''   wire   for   the 


>'■-,'  \ 


^■> 


Flu.  1!^. — Till?  aiitliur's  safety  piu  clustT. 


canals,  extra  lamps,  sterile  vaseline,  small  gauze  strips  about  4x6  cm.  in 
size  and  folded  into  sponges,  a  steel  centimeter  rule  and  battery  complete 
tbe  outfit. 

Comiuercial  lighting  circtiits  should  never  lie  used    iVir  lighting  the 


Fig.  -'•). — Aiuliur's  lar.vii;;i'al  kiiifi'. 


lamps.  .Ml  rheostats  ha.vc  one  live  side  which  may  be  "grounded"  tlirrmgh 
the  patient,  involvmg  great  danger,  even  if  of  no  more  than  no  volts 
pressure,  on  account  of  the  good  contact  with  the  moist  mucosa,  through- 
out the  length,  of  the  tube.     Dry  batteries  (Fig.  31  )  involve  no  risk  what- 


FlG.  .30. — Fersiisou's  moutli  sas. 


ever  and  with  intelligent  care  are  perfectU"  satisfactory.  The  box  should 
have  a  rheostat  for  regulation  of  the  current.  If  much  work  is  to  be  done 
a  storage  battery  (Fig.  32')  will  be  found  conveniuit. 


30 


BATTERIES. 


If  the  operator  does  not  wear  g-lasses  habitually,  it  will  be  necessary 
to  have  spectacles  with  plain  eyes  of  larsje  size  for  the  prevention  of  infec- 


KiG.  ol. — Eight-cell  dry  battery  for  euilnsidijy. 


Fig.  o2. — Four-cell  storage  battery  for  eudoscopy. 

tion  from  coughed  out  secretions,  which  shoot  out  like  projectiles  from 
the  tubes. 

A  list  of  instruments  is  here  appended  for  convenience: 


LIST  ()/•■  IXSTRL'MHXrS.  31 

LIST  OF  TXSTR^^[F.^■TS. 

TUBICS. 

The  author's  tubes  are  made  in  the  following  sizes: 
lo  mm.  X  53  cm.  eso|)hagoscopc  for  adults. 


7 

"    >^45     ' 

children. 

7 

"    X40     • 

bronchosco])c 

adults. 

8 

"     X  20      ' 

'     tracheoscope 

adults. 

5 

•'     X  14      ' 

.                    It 

children. 

5 

•■  X30    ■ 

bronchoscope 

adults. 

5 

■■■'    >^45     • 

i                    t> 

children. 

12 

■'     X  17      ' 

■     tubular  specul 

luni. 

12 

■■    X  f7     • 

separable 

for  adults 

10 

"    X70     ■ 

S'astroscope  for 

adults. 

If  rigid  economy  nnist  be  practiced,  much  good  work  can  be  done 
with  a  7  mm.  x  45  cm.  esophagoscope,  a  5  mm.  x  30  cm.  bronchoscope,  and 
a  12  mm.  X  17  cm.  separable  speculum.  The  7  mm.  x  45  cm.  esophago- 
scope can  be  used  in  the  adult  trachea  and  main  bronchi,  but  if  used  in  the 
latter,  the  absence  of  lateral  openings  must  be  remembered.  Lateral  open- 
ings are  a  disadvantage  in  an  esophagoscope.  He  who  expects  to  work- 
to  the  best  advantage  with  any  and  every  case  encountered  will  need  the 
entire  set.     For  bronchosco])y  tubes  with  drainage  are  not  often  needed. 

The  diameters  of  the  tubes  as  here  given  are  of  the  cylindrical  tubes 
before  the  canals  are  uiade  in  the  walls.  These  canals  bulge  outward 
slightly,  thus  increasing  one  diameter,  though  this  need  not  be  taken  into 
account  as  the  resiliency  of  the  passages  more  than  compensates  for  it. 

Killian"s  tubes  are  made  in  the  following  sizes : 

For  bronchoscopy,  adults     9  mm.  x  18  cm. 


" 

" 

9    ' 

■     X25 

ii 

9 
"        9     ' 
children  7     ' 

"    >;35 

"    X41 

'    >^  13 

^t 

( 

7 

"    x  18 

n 

ti 
a 

7 
7 

"    X23 

"    x28 

esophagoscopy 

adults 

7 
1 1 

"  X35 
•    X19 

*' 

II 

"    X32 

C4 

•' 

1 1 

"    -^45 

(( 

a 

II 

"    X52 

a 

a 

13 

"    X19 

it 

a 

13 

"    X  24 

it 
ti 

ti 

a 

13 
13 

"    X32 

"    X42 

t  ( 

a 

13 

"    X52 

32  .-ICCRSSORIHS. 

For   esoj)hagoscopy   in   children   the  y   mm.   bronchoscopes  are  used. 

One  universal  handle  for  all  tubes. 

Tube  spatulas,  three  sizes. 

Tube  spatulre,  split,  three  sizes. 

The  following  list  of  accessories  will  be  found  to  contain  the  essen- 
tials : 

ACCESSORIES. 

Aspirator  and  tuljing". 

3  mm.  X  ()0  mm.  extra  drainage  tube. 

3  ■■     >^40 

4  •■     x84 ' 

I    forceps  25  cm.  canula  and  4  jaws. 

I  ■■       .VS 4     " 

I  "       60     "  ■'  ■■     4     " 

I  "       84 4     " 

yi   doz.  sponge  holders  2^  cm.  long. 

i^     '•  •■'  ••        66      ■'      ■' 

I       "  ••  ■■        84      "      " 

I   hook  and  probe  25  cm.  long. 

I         "  '•  ()0      '■ 

I        ■■  ••  84     •■         " 

I   Lister-Killian  hook    23  cm.   long. 

I        '■  ■■  '■       60     ■■ 

I        •'  ••  "       84     "        " 

I  safetv  pin  closer,   3  mm.  ring,   30  cm.  long. 

I       "■'      ••         •■      10      •■       •■'     60     •■       " 

I  Sajous  laryngeal  sponge  forceps,     (curved) 

I  .Laryngeal  knife. 

I  ■'  cautery  electrode  and  cord. 

1  "  galvanic  electrode   (monopolar)  and  cord. 
y2  doz.  extra  lamps. 

2  wires  for  cleaning  canals. 

I   sterilizing  tube  for  packing  sterilized  extra  lamps. 
Eye  glasses  for  the  protection  of  operator's  eyes. 
I  double  bronchoscopic  battery  and  conducting  cords. 
I  extra  battery  cord. 


CHAPTER    III. 
Acquiring  5i<:ill. 

As  bronchoscdin-  with  the  avera,c:e  laryngologist  or  surgeon  is  rela- 
tivelv  a  rare  procedure,  some  prehminary  practice  is  advisable.  If  Killian 
tubes  with  the  Kirstein  headhght  are  used  considerable  preliminary  train- 
ing will  be  necessary  to  keep  the  light  projx'rly  directed  down  the  lube, 
and  the  general  physician  or  surgeon,  who  has  had  no  experience  whatever 
with  even  the  ordinary  head  mirror,  will  find  that  long  preliminary  prac- 
tice is  necessary  in  order  to  see  anything.  With  the  distally  illuminated 
tubes  anyone  can  see  clearly.  line  author  has  frequently  had  physicians 
totally  unfamiliar  with  tube  work,  discuss  appearances  at  their  first  exami- 
nation in  a  way  that  revealed  the  fact  that  they  had  obtained  good  clear 
views.  Nevertheless,  some  practice  is,  of  course,  necessary.  Endoscopy 
is  in  no  case  like  looking  through  an  opera  glass.  Many  details  require 
attention.  Lights  are  to  be  cleaned  and  readjusted,  secretions  to  be  con- 
tended with,  cough  and  reflexes  to  be  combatted. 

The  first  step  should  be  the  technical  management  of  the  miniature 
electric  lights  and  the  batteries.  If  possible,  this  should  be  acquired  by 
instruction.  If  not  possible,  the  details  may  be  worked  out  by  experiment. 
After  burning  out  a  few  lamps,  the  current  strength  they  will  stand  is  soon 
learned.  If  too  strong  it  will  shorten  the  life  of  the  lamp  even  if  it  does 
not  immediately  burn  it  out.  All  lamps,  whether  used  in  tubes  or  on  head- 
lamps, must  be  adjusted  by  watching  the  filament.  It  will  never  do  to 
start  using  the  tube  and  then  run  up  the  rheostat  until  the  ojierator  thinks 
he  is  getting  enough  light  on  the  object.  This  will  mean  no  end  of  trouble. 
Every  lamp  will  stand  just  so  much,  and  no  more.  This  amount  gives 
what  is  called  full  illumination.  It  is  not  easy  to  describe,  further  than  to 
say  that  it  is  the  point  where  the  filament  seems  to  grow  thicker  and  turn 
white,  just  beginning  to  lose  the  yellow.  \\'hen  first  commencing  to  glow, 
it  is  red.  As  the  rheostat  is  run  up,  it  turns  to  yellow,  and  then  to  white. 
\\'hen  just  commencing  to  turn  white  is   the  point  of  full   illumination. 


34  TESTING  LIGHTS. 

If  pushed  to  intense  dazzling  whiteness,  it  is  overilluminated  and  will 
soon  burn  out ;  while  if  only  yellow,  with  the  filament  plainly  visible,  it  is 
underilluminated  and  useless.  Until  this  is  thoroughly  mastered,  it  is  use- 
less to  attempt  endoscopy.  Many  utter  failures  have  been  due  to  rushing 
into  endoscopv  on  the  living  without  a  full  mastery  of  the  purely  mechani- 
cal details  of  the  instruments. 

Some  practical  experience  in  the  location  of  electrical  troubles  is  ex- 
ceedingly useful  and  can  only  be  acquired  b}'  practical  experience  with  elec- 
trical api^aratus.  An  automobile  ignition  experience  may  help.  A  skill- 
ful experienced  operator  will  quickly  locate  the  cause  of  "no  light"  where 
the  inexperienced  will  give  uji  in  despair.  All  electrical  apparatus  turned 
out  for  medical  work,  including  that  for  endoscopv  is  too  flimsv.  The 
wires  are  too  fine,  the  switches  and  rheostats  too  delicate.  Of  course, 
even  if  perfect  in  construction,  wear  and  also  damage  by  transportation, 
rough  handling,  sterilization,  and  other  things  will  cause  broken  circuits, 
short  circuits,  and  "no  light."  The  best  way  is  to  have  a  definite  routine 
for  locating  trouble.     The  following  order  is  a  good  one: 

1.  See  if  your  switch  is  on  and  the  rheostat  where  it  ought  to  be, 
pressing  the  levers  to  see  if  they  have  sprung  away  from  contact. 

2.  Test  all  contacts  and  connections  by  screwing  home  the  lamp, 
twisting  the  bayonet  catch,  screwing  down  the  thumb  nuts  on  the  binding 
posts. 

3.  Next  try  a  new  light  carrier  that  lighted  uy  ])ro])erly  before.  If 
this  lights  u[),  the  trouble  is  in  the  previously  used  light  carrier  or  lamp, 
which  of  the  two  being  quickly  located  by  trying  a  new  lamp.  If  the  light 
carrier  which  worked  perfectly  before,  fails  to  light  up,  trv  a  new  cord,  or 
if  this  is  not  at  hand,  close  the  circuit  from  one  binding  post  to  the  other 
through  the  light  carrier. 

If  at  any  time,  the  light  flashes  on  again,  note  where  you  were  touch- 
ing the  apparatus  at  the  time,  as  there  is  likely  a  loose  connection  at  the 
point,  brought  into  contact  by  your  touch. 

These  tletails  are  soon  learned  and  are  necessary  with  any  endoscopic 
apparatus,  unless  an  electrician  be  available  in  the  operating  room. 

The  location  of  "no  light"  troubles  with  the  Ivirstein  headlamp  is 
much  the  same.  First,  see  if  the  current  is  on  by  turning  on  one  of  the 
room  illuminating  lamps.  Tlien  test  the  Kirstein  lamp  to  see  if  it  is  screw- 
ed home,  or,  if  the  glass  looks  blackened  on  its  interior  surface,  trv  a  new 
one.  Next,  test  the  cord  as  before  described,  then  the  switch,  then  the 
binding  posts  and  rheostat.  Usually  the  commercial  lighting  circuit  is 
used,  and  rheostats  for  this  purpose  as  made  at  the  present  day  are  flimsy 
and  subject  to  constant  disorder.  Two  or  more  are  necessary  as  at  least 
one  will  be  always  at  the  factory  for  repairs.    Tliere  is  no  need  for  Ibis  to 


.icurih'ixa  SKILL. 


85 


be  the  case,  but  such  seems  to  be  the  condition  of  meiiico-electrical  nianu- 
faeturing  to-day.  Doubtless  there  would  be  less  trouble,  too,  if  physi- 
cians were  better  skilled  in  electrical  mechanics. 

After  the  details  of  batteries  and  lights  have  been  mastered  some  fa- 
miliarity with  the  manii)ulations  may  be  gained  from  tubal  exaiuinations 
of  the  interior  of  the  clenched  fist,  pushing  the  tube  ilnwii  ihrnugh  it  from 
the  upper  (radial)  side. 

The  rubber  manikin  of  Killian  (big.  S3)  is  '^■^"''}'  "seful  for  i)r;ictice, 
being  ingeniously  designed  to  sinudate  actual  obstacles  to  the  intn.KJuction 


1' IG.  ;!3. — Killiau's   niniiikia   for  practiuin^'  lii-ouchoscnpy   anil   esophagoscopy. 

of  a  tube  through  the  natural  passages.  The  dog  offers  a  convenient  ani- 
mal subject  for  ]nactice.  Chloretone  hypodermaticallv  in  doses  of  I 
gramme  is  a  convenient  anesthetic  for  the  dog.  The  author's  preference 
is  for  scopolamine  gr.  i/ioo  (0.00065  gm-)  with  morphin  gr.  1/2 
(0.0324  gm.)  given  hypodermatically  one  hour  before,  and  repeated,  if 
there  be  no  signs  of  oncoming  stupor,  twenty  minutes  before  the  time  for 
practice. 


36  .-ICOUIRIXG  SKILL. 

Much  available  material  is  wasted  about  the  average  clinic.  Cases  of 
gfoitre  that  complain  of  dys]jnoea,  justify  tracheoscopy,  and  any  case  of 
goitre  which  by  its  size  demands  o])eration  should  be  tracheoscopized  for 
tlie  information  yielded.  Cases  complaining  of  difficulty  in  swallowing 
are  neglected  or  sent  to  the  general  medical  or  gastro-enterologic  clinic, 
when  in  reality  it  is  the  plain  duty  of  the  laryngologist  to  find  out  by  direct 
laryngoscopy,  and  by  esophagoscopy  idiy  they  cannot  swallow.  Patients 
wearing  tracheal  canulse  would  be  the  better  for  a  tracheoscopic  watcii 
upon  their  endotracheal  condition.  Mucosal  inflammations  and  ulcera- 
tions, perichrondrial  and  chondrial  diseases  could  be  detected  and  cured. 
A]\  this  material  is  at  the  present  writing  wasted  in  all  the  clinics  of  this 
country,  to  say  nothing  of  the  neglect  of  the  patients'  best  interests. 


CHAPTER  IV. 

Technic  of  Direct  Laryngoscopy  and  Tracheo- 
bronchoscopy. 

General  Considerations. 

Asepsis.  It  cannot  be  too  strongly  emphasized  that  the  strictest  de- 
tails of  aseptic  technic  must  be  followed  out.  Tliis  will  limit  infective 
risks  to  those  organisms  already  present  in  the  mucosa.  If  this  be  not 
(lone,  sooner  or  later,  the  operator  will  have  upon  his  conscience  the  bur- 
den of  having  inoculated  a  fellow  creature  with  syphilis.  di])htheria.  ery- 
sipelas, tuberculosis  or  other  infection. 

In  regard  to  the  field  of  operation,  absolute  asepsis  is  impossible,  but 
the  mouth,  the  most  septic  portion  of  the  tract,  can  be  put  in  a  relatively 
clean  condition. 

A  definiti;  routine  position,  of  all  tallies,  instruments,  liatteries,  assist- 
ants and  nurses  should  be  followed,  otherwise  all  is  confusion,  which  is  not 
conducive  to  good  work.  Ouiet,  orderly  ])roc.?dure  is  essential.  Sterile 
caps  should  be  worn  as  well  as  gowns,  to  {)revent  infection  of  instruments 
in  passing  them  to  and  fro,  especially  the  long  instruments,  particularly 
when  an  assistant  or  the  operator  stoops,  kneels  or  sits. 

llie  patient  is  clothed  in  a  sterile  gown  if  the  sitting  [josture  is  used; 
or  covered  with  the  usual  sterile  sheet  and  towels  if  examined  in  dorsal 
decubitus.  Either  way  he  should  wear  a  sterile  rubber  cap  pulled  well 
down  over  the  ears. 

StcriIi.':aflon.  All  instruments  except  the  light  carriers,  battery  cords 
and  aspirator  can  be  boiled.  The  light  carriers  should  be  immersed  in 
alcohol  before  using  and  a  stock  of  lamps  already  sterilized  shoufd  be 
packed  in  glass  sterilizing  tubes.  The  battery  cords  are  rubber  covered 
so  they  can  be  wiped  with  mercuric  bichloride  solution.  The  a.spirator  is 
immersed  in  5  ])er  cent,  carbolic  acid  solution,  which  is  also  pumi)ed 
through  it  a  luimlier  of  times.     It  is  then  rinsed  in  sterile  water. 


38  BRONCHOSCOPY. 

If,  during  the  course  of  an  upper  bronchoscopy,  it  is  decided  to  do  a 
lower  bronchoscopy,  everything  should  be  resterihzed  before  opening  the 
trachea,  provided  there  is  time.  Sterile  tracheotomy  instruments  should 
be  at  hand  on  a  separate  table  where  they  will  not  get  soiled  while  work- 
ing with  the  bronchoscopes  through  the  mouth,  and  where  they  are  reail}' 
for  immediate  use.  If,  as  will  occasionally  happen,  an  immediate  trach- 
eotomy is  required,  it  is  an  advantage  to  have  an  assistant  who  has  not 
been  contaminated  with  the  mouth,  or  the  instruments  used  therein,  to 
stab  the  trachea.  In  any  case  there  will  be  ample  time  to  resterilize  all 
tracheo-bronchoscopic  instruments  before  introducing  them  into  the 
trachea,  and  it  is  utterly  unjustifiable  except  in  dire  emergency  to  intro- 
duce through  a  tracheotomy  wound,  the  instruments  soiled  in  the  mouth. 
It  may  be  argued  that  in  upper  bronchoscopy  the  tubes  are  introduced 
through  the  mouth,  but  they  are  introduced  through  a  split  spatula  and  no 
great  amount  of  infective  material  need  be  carried  downward.  Besides, 
one  great  advantage  of  lower  bronchoscopy  is  its  asepsis,  and  this  advan- 
tage will  be  lost  if  instruments  infected  in  the  mouth  be  used  without  re- 
sterilization. 

During  an  examination  the  small  lights  require  cleansing  frequently, 
the  light  carrier  being  withdrawn  for  the  purpo:-e.  \\  ith  trained  help  this 
requires  but  a  moment.  Occasionally  it  will  be  found  that  the  ciu'rent 
requirements  of  the  lamps  vary,  and  a  little  readjustment  of  the  rheostat 
is  necessary  for  a  fresh  lamp.  For  rapid  work,  it  is  imperativelv  necessary 
to  have  a  trained  assistant  who  is  thoroughly  familiar  with  all  the  appara- 
tus, and  also  a  nurse  who  is  trained  to  keep  the  lamps  and  tubes  clean  and 
in  good  order  while  working,  so  that  the  operator  has  nothing  to  do  but  to 
observe,  while  armed  sponge  holders,  forceps,  probes,  hooks,  fresh  light 
carriers  with  lights  properly  illuminated  are  handed  to  him  as  called  for. 

A  stock  of  extra  miniature  lamps  should  be  kept  sterile,  packed  in 
glass  sterilizing  tubes  with  a  wad  of  cotton  between  each  lamp,  so  that  a 
single  extra  lamp  can  be  taken  out  when  needed  without  infecting  the 
others  more  deeply  placed.  In  this  way  the  extra  lamps  are  always  ready 
and  never  need  sterilizing  but  the  once. 

Unilluminated  tubes  should  never  be  boiled  as  boiling  soon  dulls  the 
brilliancy  of  their  interior  polish. 

Preparation  of  the  patient.  Foreign  body  cases  will  often  be  dealt 
with  without  pre]5aration  of  the  patient.  Where  there  is  time,  as  there 
usuallv  is  in  most  other  cases,  and  in  many  foreign  body  cases,  it  is  best 
to  insist  upon  proper  preparation.  A  purge  should  be  given,  and  no  food 
allowed  for  6  hours  for  tracheo-bronchoscopy.  8  hours  for  esophagos- 
copy  and  12  hours  for  gastroscopy.  Even  in  direct  laryngoscopy  the  pres- 
ence of  the  instrument  in  the  pharynx  may  excite  vomiting  if  there  be  food 


DIRECT  LARYXGOSCOPy.  39 

in  the  stomach.  The  possiljlc  need  for  general  anesthesia  also  renders 
fasting-  necessary  in  a  Ux-ally  anesthetized  case.  If  the  patient  has  just 
eaten.and  delay  is  inadvisable,  lavage  of  the  stomach  is  called  for. 

The  nearest  approach  to  oral  asepsis  is  imperative.  Whenever  practi- 
cable the  teeth  should  be  put  in  the  best  of  condition  by  the  dentist. 

The  patient  is  then,  directed  to  brush  his  teeth  with  soap  and  chalk 
and  to  rinse  his  mouth  every  two  hours  with  thirty  per  cent  alcohol.  As 
shown  recently  by  Dr.  A.  \\'adsworth.  alcohol  is  the  most  efficient  oral 
antiseptic.  A  more  eligible  preparation,  as  advocated  by  Wadsworth,  is 
made  bv  adding  sodium  bicarlx>nate  and  chloride  in  normal  salt  propor- 
tions and  spirits  of  chloroform  and  oil  of  wintergreen  as  flavoring  to  the 

alcohol. 

The  patient  should  wash  his  face  thoroughly  with  soajj  and  water,  be- 
mg  particularlv  thorough  with  beard  or  mustache  if  he  have  these  ;  and  he 
should  rinse  first  with  water  and  then  with  i  :iooo  perchloride  of  mercur_\- 
sohition. 

DIRRCT  L.VRYNGOSCOPY. 

Anesthesia.  For  ordinary  routine  work  either  in  the  consulting  room 
or   in   the  operating  room,   local   anesthesia  is   sufficient.     A  4  per  cent 


Fn;.  34. — Sajous'  cotton   liolilins  forcin»     for    prelimhinr.v    oocainizntioii     of    the 
larynx  and   pliar.vnx. 

solution  of  cocain  is  applied  w  ith  a  mop  of  cotton  held  in  the  Sajous  for- 
ceps (Fig.  34).  After  waiting  a  few  moments,  the  laryngeal  speculum 
(Fig.  6)  is  introduced  until  the  epiglottis  appears  and  a  more  accurate 
apphcation  is  made  to  the  epiglottis  and  all  tissues  in  its  neighborhood. 
Then  the  instrument  is  passed  posteriorly  to  the  epiglottis,  bringing  into 
view  the  interior  of  the  larynx  and  the  introitus  esophagi,  which  are  swept 
over  with  a  20  per  cent  solution.     Cotton  mops  may  be  used  for  this. 

For  operative  work,  where  there  is  no  dyspnoea,  a  general  anesthetic 
should  be  used,  as  the  relaxation  and  absence  of  tetanic  reflexes  renders  the 
examination  very  nnich  easier.  It  is  not  painful,  though  a  spectator  would 
not  believe  this,  as  in  many  instances  the  patient  looks  as  if  he  were  chok- 
ing to  death.     Cocain  must  he  used  cautiouslv  in  children. 


40 


TECHNIC 


If  a  general  anesthetic  be  used,  chloroform  is  preferable;  being  con- 
tinued, after  the  examination  starts,  by  a  gauze  sponge  held  with  a  hem- 
ostat  and  saturated  with  chloroform.  This  is  held  over  the  mouth  and 
nostrils,  or,  if  the  jiatient  has  been  tracheotomized,  over  the  tracheotomy 
wound. 

Direct  laryiii/oscol^y.  Patient  sittiiu/.  For  ordinary  routine  direct  lar- 
yngoscopy in  the  consulting  ro(^m,  the  patient  sits  upon  a  low  stool,  the 
assistant  sits  on  a  higher  stool  or  stands  behind  the  patient  and  holds  the 
gag  and  the  head  an<l  keeps  the  lip  out  of  the  way,  so  that  it  will  not  hs 
pinched  betweeri  the  instrument  and  the  upper  teeth.  It  is  possible  to  hold 
even  an  unrulv  child  bv  using-  the  followins;  method  :     The  nurse  holds  the 


Fli;.  .'I.'i.  —  IHrrct   Un-yiiuescoiiy.      I'aticiil    ^iliiii^. 

child's  knees  between  her  own,  crossing  her  arms  in  front  of  the  child  and 
catching  opposite  hands  with  the  child.  The  head  on  her  shoulder  is  held 
by  an  assistant.  Another  way  is  to  wrap  the  child  in  a  sheet.  The  author 
does  not  advise  working  thus.  Dorsal  decubitus  is  better  with  unruly 
children,  and  the  author  ]irefers  it  under  almost  all  conditions. 

In  the  operating  room  the  posture  of  the  patient  and  tke  positions  of 
the  second  assistant  and  the  nurse  are  as  shown  in  Figs.  35  and  36.  The 
operator  in  the  position  shown  in  Fig.  ;^j.  I^'orceps  and  other  instruments 
are  handed  as  called  for. 

The  duties  of  the  first  assistant  are  to  hand  all  in.struments  to  the  ope- 
rator in  the  piosition  for  insertion  with  their  axes  corresponding  to  that  of 


DVTir.S  OF  .LSSfSTANTS. 


41 


tlio  tulie.  }\e  shoulil  do  this  with  his  ri5:jht  hand  while  in  his  left  he  holds 
a  half  dozen  or  more  sponge-holders,  which  are  handed  as  needed  to  the 
patient  sits  on  a  low  stool,  the  second  assistant  sits  on  a  higlier  stool  back 
of  the  patient.  Tlie  first  assistant  and  the  nurse  are  to  the  right  of  the 
o|)erator  with  the  instrument  table  between  them.  (These  are  removed  in 
in  the  cut  so  as  not  to  hide  the  positions,  etc. )  The  battery  is  on  a  low 
strong  table  to  tlie  left.  It  is  covered  with  sterile  towels  on  which  the  cord 
may  be  laid  when  not  in  use.  The  knob  of  the  riieostat  can  be  felt  through 
the  towel  and  moved  as  needed. 

The  duties  of  tlie  nurse  are  to  stand  back  of  the  table  (the  first  assist- 
ant being  in  front)  to  refill  the  sponge-holders  as  they  are  laid  down  on  the 
table,  soiled,  by  the  first  assistant.     As  refilled  she  lavs  them  in  position 

an  aspirator 


so  that  the  first  assistant  can  pick  them  tip  conveniently.     If  a 


OPERATOR 


^ 

!>'  ASSISTANT 

^ 

INSTRUMENl 

TABLE 

l-'io.  .^0. — Direct  lar.vngo.s(:oi).v.     I'atient  sitting.     iJiasrain  of  posilions  of  jktsous 
and  liiiiigs.     Table  slionld  be  a  little  nearer  the  operator. 


is  used  she  may  work  this,  or  it  may  be  done  by  the  second  nurse.  If  but 
one  nurse  is  to  be  had,  a  good  supply  of  sponge-holders  is  needed. 

In  looking  at  Fig.  37  the  table  would  be  the  foreground,  with  the 
nurse  to  the  right,  and  the  first  assistant  to  the  left,  as  seen  in  the  diagram 
Fig.  36. 

The  duties  of  the  second  assistant  are  extremely  important.  He  must 
liold  the  patient's  head  bent  backward,  with  the  trunk,  and  especially  the 
neck  pushed  forward,  the  bend  being  as  much  as  possible  in  the  region  of 
the  axis  and  adjacent  cervical  vertebrae.  At  the  same  time  he  holds  the 
mouth  widely  open  with  the  gag,  and  in  a  case  of  a  sitting  patient,  with 
the  forefinger  he  keeps  the  patient's  upper  lip  away  from  the  upper  teeth. 


42 


USE  OF  LARYNGEAL  SPECULUM. 


He  should  realize  the  importance  of  his  duties,  and  that  a  cut  upper  liji 
means  the  most  reprehensible  carelessness  upon  his  part. 

All  of  the  details  as  here  given  are  not  absolutely  necessary  for  the 
brief  examination  in  the  consulting  room ;  but  for  more  prolonged  exami- 
nations, removal  of  foreign  bodies,  and  certainly  for  all  operative  proced- 
ures attention  to  all  the  details  given  is  absolutely  essential,  as  already 
mentioned,  for  good  work. 

Using  the  laryngeal  speenhiui.  The  light  on  head  lani])  or  light  car- 
rier having  been  adjusted  to  the  proper  brilliancy,  and  the  field  being  an- 
esthetized, the  tubular  speculum  is  inserted  until  the  epiglottis  appears  in 
view.     The  flat  end  of  the  tube  is  passed  behind  the  epiglottis  about  a 


I'll;.    '.1.      Liiwur  traclit'o-broiicliosciipy.      I'atirut  siltiiij;. 


centimeter,  and  now  comes  the  only  point  where  difficulty  in  the  manipula- 
tion is  encountered.  Once  this  knack  is  acquired,  no  difificult}-  will  be  met 
with.  The  epiglottis  must  be  pushed  forward  tightly  against  the  base  of 
the  tongue,  which,  with  the  tissues  attached  to  the  hyoid  bone,  must  be 
forcibly  pushed  forward  out  of  the  line  of  vision.  This  pushing  is  done 
with  the  spatular  extremity,  the  directioii  of  motion  being  shown  schemat- 
ically in  Fig.  38.  The  instrument  is  given  a  forward  motion  of  the  tip  by 
an  upward  and  backward  motion  of  the  handle,  the  pivotal  point  bemg  at 
the  junction  of  handle  and  tube.  By  this  it  is  not  meant  that  the  tube 
rests  on  the  upper  teeth.     This  is  the  first  and  most  serious  error  made  bv 


Tf.CHNIC. 


43 


the  iiu'xp.Ticnccl.  li  is  mtcrly  impossible  to  get  a  good.  view,  of  the 
laryii.x  if  the  upp-''-  t^^'th  are  used  as  a  fulcrum  to  pry  the  mouth  open  and 
the  hyoid  tissues  forward,  and  the  strength  required  is  painfully  great  for 
both  patient  and  operator. 

Another  error  frequently  ronnnitted  by  the  inexperienced  is  the  inser- 
tion of  the  speculum  too  deeply,  so  that  it  gets  behind  the  cricoid  cartilage. 
This  is  evidenced  h\  interference  with  the  patient's  breathing,  by  the  open- 
ing up  of  the  upper  end  of  the  csojihagus  to  view  and  resistance  to  the  for- 
ward pressure  of  the  tip  of  the  mstrument.  Under  these  circumstances, 
when  the  specuUnn  is  withdrawn  slightly  the  "brassy"  tubular  respiratory 
sound  denotes  the  right  place.  One  soon  learns  to  tell  by  the  sound  when 
tubes  are  at  the  laryngeal  orifice. 

Upper  tmcheo-bronchoscopy.  Silting  posture.  If  desired,  as  in  se- 
vere dvspnoea.  the  bronchoscope  may  be  passed  with  the  patient  seated. 


j.'iQ    38.— Diagrammatic  represeutation  of  direct  laryngoscopy  and  scliema.  sbow- 
iug  dh-ection  of  force  applied  in  usiug  llie  tubular  speculum  and  separable  spatula. 

The  split  tubular  speculum  is  used  and  the  bronchoscope  passed  as  shown 
in  Fig.  39,  which,  however,  shows  the  first  assistant  in  the  wrong  position, 
the  correct  one  being  as  in  Figs.  36  and  37.  Hie  technic  is  the  same  as 
described  for  the  recumbent  posture.  The  author  prefers  the  latter  post- 
ure for  bronchoscopy  and  he  would  tracheotomize  patients  too  dyspnoeic 
to  lie  down  without  it  Should  tracheotomy  be  demanded,  it  is  an  advan- 
tage for  the  patient  to  be  already  recumbent  upon  the  tal)le.  \Mien  a  gen- 
eral anesthetic  is  used  recumbency  is  imperative.  Fig.  39  .shows  left  upper 
bronchoscopy,  the  split  tubular  spatula  in  the  right  buccal  angle,  the  bron- 
choscope passed  througli  the  tubular  spatula  which  has  not  yet  been  re- 
moved. The  second  assistant  holds  the  gag  in  the  right  side  of  the  pa- 
tient's mouth,  while  with  his  left  forefinger  he  elevates  tb.e  patient's  upper 
lip  at  the  left  side  (removed  when  the  photograph  was  taken  so  as  not  to 
hide  the  instruments). 


44 


TRACHEO-BROXCHOSCOPy. 


Fii;.   '.i'J. — \jnit    u\)\)vv    iracliHu-brimsfUoscopy.     Patient    >ittiLig.      First    assistant's 
position  should  be  as  shown  in  Figs.  30  and  37. 


Fid.  40. — Left  upper  tracheo-bronchoscopy,  showing  the  introduction   of  broncho- 
scope through  the  separable  speculum. 


TRACHF.O-BRONCHOSCOPY.  45 

Urwcv  tyachco-bronchoscofx.  Stttuui  tosturc.  (  Fis,'.  37-  I  This  also 
is  not  advisable  for  prolonged  work,  hut  it  is  perfectly  feasible.  It  is  a 
..reat  convenience  and  should  always  he  used  in  one  class  of  cases :  namely, 
walking  cases  wearing  tracheal  eanuUe.  A  close  watch  should  be  kept  on 
these  cases,  for  tjranulations,  ulcers,  et  cetera,  in  the  trachea.  I  lus  is 
easily  and  quicklv  done  with  a  short  tracheoscope,  which  is  nu.ch  better 
than  anv  form  of  dilator  tor  even  the  deeper  parts  of  the  wound,  wlule  for 
the  trachea  itself  it  is  the  only  wav  that  ulcers,  granulations,  etc..  may  be 
treated  and  cicatrices  and  stenotic  webs  prevented.  Shenild  dyspnoea 
supervene  when  the  tracheal  caiuila  is  removed,  a  quick  inserti..n  ot  the 
tracheoscope  will  give  instant  relief. 

If  previously  tracheotomized  the  bn.nchi  may  be  examined   in  this 


wav 


Of  course  in  patients  just  tracheotomized.  the  recumbent  posture  is 
used   and  the  author  prefers  recumbency  in  all  cases, 

Direct  laryu^oscotx.  dorsal  decubitus.  The  chief  differences  between 
direct  larvngosccipN-  with  the  patient  in  the  sitting  and  dorsally  decumbent 
positions.' are  in  the  arrangement  of  nurses,  assistants  and  operating  room 
detail  and  in  the  manner  of  grasping  the  tubular  speculum.  The  operating 
room  arrangement  is  the  same  as  described  in  the  following  pages  under 
"Upper  tracheo-bronchoscopy." 

The  manner  of  making  pressure  with  the  tube  does  not  differ  so  far  as 
the  relation  of  tube  to  the  patient's  anatomy  is  concerned.  The  tubular 
spatula  is  grasped  f^rmlv  in  the  operator's  left  hand,  as  shown  in  Fig.  40, 
and  the  motion  .shown  in  the  schema  (  Fig.  38)  is  imparte.l  to  it,  as  if  to 
lift  the  patient  off  the  table  with  the  tip  of  the  speculum,  or  as  if  to  force 
the  epiglottis  out  between  the  hyoid  bone  and  the  thyroid  cartilage  with 
the  tip  of  the  speculum.  Care  must  be  taken  to  avoid  mistaking  the  infe- 
rior constrictor,  or  a  glosso-epiglottic  fold  for  the  epiglottis. 

UPPER    TR.VCHF.O-BRONCHOSCOPV,    DORSAL    DKCIJBITUS. 

Posture  and  oilier  detaUs.  The  patient  lies  upon  an  operating  table, 
the  foot  of  which  is  15  inches  lower  than  the  head.  The  table  shown  in 
the  figure  40  was  designed  by  the  author  for  this  and  other  throat  work. 
It  is  pivoted  horizontally  in  the  center  so  that  it  balances  and  no  matter 
how  heavv  the  patient,  it  is  easily  raised  or  lowered.  The  headlioard  is 
only  dropped  after  the  second  assistant  is  ready  to  support  the  head.  Most 
tables  have  a  dropping  headboard  of  this  kind,  but  if  not  the  patient  must 
be  moved  until  his  shoulders  slightly  overhang  the  edge  of  the  table. 
\\''hen  everything  is  ready,  lights  regulated,  tubes  greased,  sponge-holders 
armed,  assistants  in  position,  the  headboard  is  dropped  and  the  patient's 
head  is  in  the  air  free  to  move  in  every  direction  (Fig.  40)  under  the  con- 


46 


TRACHEO-BRONCHOSCOPY. 


trol  of  the  second  assistant,  who  (in  left  upper  bronchoscopy)  sits  upon  a 
high  stool  on  the  right  side  of  the  patient,  his  right  arm  back  of  the  pa- 
tient's neck,  holding  the  gag  in  the  left  side  of  the  patient's  mouth,  while 
his  left  hand  supports  and  controls  the  patient's  head  from  underneath,  the 
hand  resting  upon  his  (the  assistant's)  knee,  which  is  elevated  to  the 
proper  height  by  a  footstool  or  by  crossing  one  knee  over  the  other,  de- 
pending upon  the  height  of  the  table.  In  this  position  the  second  assistant 
can  do  his  duty  without  undue  fatigue  during  a  prolonged  search  or  opera- 
tion. As  before  stated,  the  second  assistant  is  the  most  important  factor 
in  the  work.  His  work  is  fatiguing  and  he  should  be  made  as  comfort- 
able as  possible.  The  holding  of  the  gag  is  a  thing  that  few  men  ever  do 
correctly.  The  best  gag  is  Ferguson's,  and  it  must  be  placed  on  the  canine 
or  lateral  incisor  teeth,  not  back  on  the  molars,  where  it  is  sure  to  slip.     It 


NURSE 


STRUMENT 
TABLE 


I'.'  ASSISTANT 


0 


OPERMOR 


:V  ASSISTANT  j 


^ 


OPERATING 
TABLE 


ane:sthetist 


Fi(i.  41. — Direct   laryugoscopy.  tiMrlii'ij-ljnmi-hoscuii.v.   esopliagoscopy.  gastro.'iooiiy. 
Patiei.l    itoi'mbent. 

is  placed  on  the  side  of  the  mouth  opposite  to  that  through  which  the  tube 
is  passed. 

In  order  to  take  the  jihotograph  tlie  operating  room  arrangement  was 
disturbed.  It  is  shown  diagrammatically  in  Fig.  41,  and  it  is  very  essential 
that  this  arrangement  be  strictly  follov\'ed,  otherwise  all  will  b^chaos  with 
the  long  instruments  needed  in  upper  tracheo-bronchoscopy.  The  duty  of 
the  first  assistant  is  to  pass  instruments,  always  in  position  for  insertion. 
The  nurse  works  the  aspirator,  refills  sponge -holders,  and  cleans  the  in- 
struments. 


ANESTHESIA.  47 

The  anesthetist  stands  upon  the  left  side  of  the  patient  and  wlicther 
giving  the  anesthetic  or  not.  must  keep  the  hp  of  the  patient  away  from  the 
edge  of  the  teeth  with  the  loft  forefinger.  This  duty  cannot  he  performed 
hv  the  second  assistant  with  a  recumbent  patient. 

Anesthesia.  The  examination  of  the  bronchi  is  perfectly  feasible  un- 
der cocain  anesthesia.  especiall\-  if  a  large  dose  of  morphin  be  given: 
the  morphin  adding  courage,  rather  than  anestliesia :  but  except  in  dysp- 
noeic  cases  the  author  prefers  chloroform,  and  in  any  case  he  considers 
morphin,  with  its  prolonged  alx>lition  of  the  cough  reflex  unsafe.  The 
cough  reflex  is  the  watch-guard  of  the  lungs,  by  which  infective  or  dele- 
terious materials  are  removed. 

Cocain  is  first  applied  as  described  when  writing  of  direct  laryn- 
goscopv. 

After  the  glottis  is  passed,  the  tracheal  antl  bronchial  mucosa  are 
anesthetized  a  portion  at  a  time  in  stages  as  the  tulx^  is  advanced,  using 
cotton,  or  as  the  author  prefers,  gauze,  sponges. 

Chloroform  is  given  in  the  usual  way  on  an  Esmarch  i'.ihaler  until  the 
patient  is  fullv  under  its  influence.  Then  the  split  spatu'.a  is  inserted  and 
the  lar>nx  is  mopped  with  20  per  cent  cocain  solution.  It  is  often  pos- 
sible to  anesthetize  the  trachea  also  thus  through  the  tube  spatula  with  a 
long  applicator.  After  the  bronchoscope  is  passed  the  cocain  solution  is 
apiilied  to  the  tracheal  and  bronchial  mucosje  from  time  to  time.  In  this 
way  a  minimum  amount  of  chloroform  is  needed  and  the  cardiac  stimu- 
lant effect  of  the  cocain  is  a  safeguard  of  value. 

After  the  bronchoscope  is  passed  the  chloroform  is  dropped  upon  a 
gauze  sponge  held  intermittently  in  front  of  the  tube,  for  but  little  air  is 
taken  in  past  the  tube  which  is  clamped  in  the  glottis  by  the  reflex  spasm 
of  the  adductors. 

The  preliminary  use  of  atropine  to  lessen  secretion  as  suggested  by 
Ingals  is  a  good,  safe  procedure.  It  has  the  additional  advantage  of  pro- 
tecting the  circulation  from  shock.  Adrenalin  assists  in  this  and  also  m 
lessening  the  mucosal  swelling. 

Passhi^  the  broiicliosrope.  The  author's  first  work  was  done  by 
passing  the  bronchoscope  witli  the  left  forefinger  as  a  guide  and  fulcrum 
upon  which  the  tube  was  ti;rncd  into  and  through  the  glottis  by  a  rocking 
motion.  Tlie  pilot  was  in  situ  and  was  removed  as  soon  as  the  glottis  was 
passed.  When  Killian  devised  his  ingenious  split  tubular  spatula,  the  sim- 
pler method  was  followed.  At  present  the  author  uses  the  split  speculum 
shown  in  Fig.  7,  one  battery  cord  being  attached  to  it  and  one  to  the  bron- 
choscope. 

The  method  is  briefly  as  follows :  The  separable  speculum  is  passed 
in  precisely  the  same  way  as  is  the  tubular  speculum,  as  described  under 


48  FASS/XG  THR  BRONCHOSCOPE. 

direct  laryngoscopy.  After  the  glottic  aperture  is  brought  fully  into  view, 
the  patient,  if  under  local  anesthesia,  is  told  to  take  a  deep  breath  and  when 
the  cords  separate  the  well  greased  bronchoscope  without  a  mandrin,  with 
tubing  unattached,  is  pushed  in.  .\fter  passing  the  glottis  the  aspirating 
tubing  is  attached  if  necessary,  which  it  rarely  is. 

The  patient  does  not  always  take  the  deep  inspiration  at  command 
because  the  glottis  is  closed  by  a  spasm  of  the  adductors,  due  to  a  reflex 
from  the  presence  of  the  instrument.  He  may  be  making  violent  efforts 
to  draw  in  a  deep  breath,  but  cannot  do  so.  Slightly  withdrawing  the  in- 
strument and  a  quiet  reassurance  of  the  patient  by  the  operator  usually 
relaxes  the  spasm.     It  is  less  likely  to  occur  if  the  laryn.x  is  well  cocainized. 

If  a  general  anesthetic  be  used,  of  course  the  patient  cannot  be  told  to 
take  a  deep  breath  ;  but  anyway  it  is  needless,  as  the  rythmic  respiratory 
movements  of  the  cords  are  watched  and  the  bronchoscope  inserted  just  as 
they  are  on  their  inspiratory  abductive  excursion.  The  tube  mouth  should 
not  touch  the  cords  until  it  is  thrust  through. 

The  split  tulnilar  spatula  is  used  in  its  illuminated  form,  but  the  light 
of  the  bronchoscope  may  be  used  by  simply  holding  it  in  place  within  the 
tubular  speculum  with  the  right  hand  to  show  when  the  glottis  is  exposed 
to  view  by  the  energetic  lifting  of  the  split  tubular  spatula  held  in  the 
left  hand.  The  operator's  eye  is  held  at  the  bronchoscope,  which  is  then 
passed  by  sight. 

The  latter  plan  is  necessary  when  a  double  battery  is  not  used.  The 
mandrin  is  not  used,  and  the  battery  cord  is  attached  to  the  bronchoscope 
from  the  beginning.  In  the  first  described  plan  one  battery  cord  is  used 
on  the  separable  speculum,  and  another  cord  on  the  bronchoscope.  In 
either  method,  after  the  bronchoscope  mouth  has  passed  the  larynx,  the 
spatula  is  separated  and  removed.      (See  schema,  page  53.) 

Once  past  the  glottis,  the  entire  bronchial  tree  is  easily  explored. 

The  left  bronchus,  which  deviates  more  obtusely  from  the  trachea 
than  the  right,  is  no  more  difficult  to  enter  with  the  tube  than  is  the  right. 
The  right  upper  lobe  bronchus  is  perhaps  the  most  difficult. 

To  explore  the  right  bronchus  the  tulie  is  moved  to  the  left  angle  of 
the  moutli,  and  the  head  and  neck  of  the  patient  are  moved  slightly  to  the 
left.     The  amount  of  elasticity  of  the  bronchial  tree  is  astonishing. 

Care  must  be  taken  to  see  that  there  is  always  a  free  passage  for  air. 
As  shown  by  Killian  if  the  bronchus  examined  is  occluded  by  a  foreign 
body,  the  other  bronchus  being  shut  off  by  the  passage  of  the  tube,  will 
leave  the  patient  without  air. 

In  passing  Killian's  tubes  the  Kirstein  headlight  should  be  first  care- 
fully focused  and  then  adjusted  before  the  eye.  Then  the  tube  should  be 
warmed,  as,  if  cold,  the  polish  of  the  interior  of  the  tulic  will  be  dimmed 


TR.ICllliU-BKUXCIIUSCUry 


4SI 


by  the  condensation  of  moisture  from  the  patient's  i)reath,  wliich  will  se- 
riously interfere  with  the  amount  of  liijht  that  will  reach  the  nhject  at  the 
distal'end  of  the  tube.  Much  of  the  li,i;ln  that  reaches  ihe  hntmm  ni  the 
tube  is  not  tlie  direct  rays  but  the  rays  ret1ecte<l  from  wall  t.>  wall  one  or 
more  times  in  the  length  of  the  tube.  I'or  this  reason,  also,  the  interior  of 
the  tubes  must  be  kept  cleaned  of  secretion  and  blocd  as  thonni-hly  as  pos- 
sible during  the  examination. 

.\11  tubes,  of  whatever  kind,  should  he  lubricateil  with  vaseline.  A 
jelh-  lubricant  soluble  in  water  is  not  satisfactory.  In  the  use  of  the  unil- 
iuniinated  tubes  particular  care  should  be  taken  that  none  is  allowed  to  get 
upon  the  interior  walls,  as  this  will  diminish  the  illumination  of  the  object. 
Particular  care  is  necessary  to  see  that  a  Mirplus  does  not  get  upon  the  far 
end  of  the  tube  where  the  wididrawal  of  the  swabs  will  carry  it  into  the 

tulie. 

Another  method  of  jiassing  the  unillummated  bronchoscope  is  witn 
the  aid  of  a  catheter-like  mandrin  which  is  longer  than  the  tube  and  pro- 
jects bevond  the  tube,  acting  as  a  pilot.  As  soon  as  the  catheter  passes  the 
glottis,  the  tube  is  pushetl  on  past,  also,  and  then  the  catheter  is  (piickly 
withdrawn.  Sufficient  air  passes  through  the  catheter  to  prevent  inter- 
ruption of  respiration. 

It  may  be  in  some  cases  advisable  to  have  the  tongue  drawn  forward 
out  of  the  mouth  during  the  introduction  of  a  tube.  The  author  has  not 
found  this  necessary  except  m  a  few  instances,  even  before  the  use  of  the 
separable  spatula.  A  rocking  motion  of  the  tube,  throwing  the  distal  end 
of  the  tube  forward  and  the  proximal  end  backward,  using  the  end  of  the 
left  index  finger  as  a  fulcrum  has  always  served  the  author  better  than 
drawing  out  the  tongue  or  pulling  it  forward  with  the  Kirstein  spatula. 
Much  depends  upon  the  operator's  training.  Those  accustomed  to  intuba- 
tion will  find  their  index  finger  the  best  guide.  The  separable  tube  spatula 
has.  however,  rendered  all  other  methods  difficult  by  comparison.  Thor- 
ough masterv  of  direct  laryngoscopy  renders  bronchoscopy  easy. 

An  absolute  essential  in  the  use  of  unilluminated  tubes  is  the  skillful 
technical  management  of  the  headlamp  or  handlamp.  Many  of  the  utter 
failures  to  get  results  with  these  tubes  is  due  to  faulty  management  of  the 
Kirstein  headlamp. 

Adjustiiii^  the  Kirstein  headlamp.  I'irst  the  hood  (L  l-'ig.  i  )  should 
be  removed,  the  mirror  (S)  and  lens  cleaned  and  polished,  and  then  the 
rheostat  run  up  to  the  point  where  full  illumination  is  secured,  yet  not  so 
high  as  to  burn  out  the  lam]i  or  materially  to  shorten  its  life.  This  point 
should  be  learned  bv  demonstration  if  possible.  It  may  be  described  as 
the  point  where  the  filament  seems  to  thicken  and  grow  white,  bcuinning 
to  lose  the  vellowness  of  its  earlier  and  weaker  stage  of  illumination. 


50  TRACHEO-BRONCHOSCOPY. 

The  next  step  is  to  focus  the  rays.  The  ho<jd  (L)  should  be  moved 
upward  and  downward  until  the  proper  focus  is  found,  which  is  when  the 
rays  are  parallel  as  shown  by  the  disk  of  light  thrown  upon  the  hand  held 
up  in  front  of  the  light  and  moved  backward  and  forward.  The  disk 
should  grow  neither  larger  nor  smaller  as  the  hand  is  moved.  Pushing 
the  hood  upward  diverges  the  rays,  and  pulling  it  downward  converges 
them.  If  pulled  too  far  downward  the  rays  cross  over,  which  is  a  disad- 
vantage. Most  lamps  will  not  permit  of  pulling  down  this  far  ;  in  fact, 
many  lamps  upon  the  market  are  made  so  short  that  the  hood  will  come 
clear  off  before  parallel  rays  are  obtained. 

Having  obtained  a  good  strong  light  and  parallel  rays,  the  headband 
is  adjusted  to  the  head  and  the  hole  in  the  lens  is  brought  directly  in  front 
of  the  pupil  of  the  right  eye.  Closing  the  left  eye,  the  operator  looking 
through  the  hole  witii  the  right  eye  adjusts  the  mirror  until  the  image  of 
the  light  can  be  seen  upon  the  palm  of  the  hand.  This  assures  parallelity 
of  the  illuminating  and  the  visual  axes.  This  is  absolutely  essential,  for 
while  the  walls  of  the  tube,  if  highly  polished  and  undimmed,  will  reflect 
the  rays  obliquely  backward  and  forward  until  they  reach  the  object,  yet 
the  walls  in  use  are  always  more  or  less  dimmed  by  condensation  and  se- 
cretions resulting  in  loss  of  light.  Further,  with  tubes  of  small  diameter, 
relatively  so  few  rays  enter  the  tube  that  if  there  is  even  a  little  loss  the 
object  is  verv  feeblv  illuminated.  If  in  addition,  more  light  is  cut  otf  by 
the  introduction  of  instruments  total  darkness  results. 

No  second  person  can  put  the  headlamp  on  one's  head  like  one"s  self. 
Therefore  it  should  be  put  on  and  all  adjustments  should  be  made  before 
the  hands  are  sterilized.  [Minor  adjustments  constantly  necessary  in  work, 
and  the  turning  oft'  and  on  of  the  switch  (A.  E.  Fig.  i)  if  the  cords  be 
fitted  with  one,  can  be  made  with  a  bit  of  sterile  gauze  or  a  towel,  held  in 
the  fingers. 

Lozver  trachco-broiiclioscopy.  Dorsal  dcciihitits.  This  ditters  from 
upper  tracheo-bronchoscopy  chiefly  in  operating  room  detail,  and  in  the 
much  greater  ease  of  its  performance,  especially  in  the  hands  of  the  inex- 
perienced. 

If  the  wound  be  made  expressly  for  tracheo-bronchoscopy,  all  bleed- 
ing is  stopped.  If  a  previously  tracheotomized  case  is  to  be  examined,  the 
wound  is  cleaned.  In  either  case  a  Trousseau  dilator  is  intro- 
duced and  the  trachea  swabbed  with  a  20  per  cent  solution  of  cocain. 
After  waiting  a  few  moments  for  anesthesia  to  take  place,  the  patient's 
head  is  turned  slightly  to  the  opposite  side  and  the  bronchoscope  is  intro- 
duced from  the  right  side  for  the  exploration  of  the  left  bronchus  and  vice 
versa.  The  bronchoscope  is  passed  carefully  by  sight  until  the  bifurcation 
is  reached.     As  soon  as  the  desired  main  bronchial  opening  is  entered, 


SELECT  I  OS  OE  TUBES.  51 

cougli  su])crvcnes  because  the  anesthetic  has  only  been  api)lie(l  to  tlie  tra- 
chea. A  swab  nn)istene(I  with  lo  per  cent  cocain  solution  is  passed  dcjwn 
and  the  nuictxsa  swabbed.  At  the  secondary  and  tertairy  bifurcations  the 
cocain  application  will  have  to  be  made,  probably  in  other  places.  This 
has  to  be  done  whether  a  f;eneral  anesthetic  is  used  or  not,  as  ether  is  con- 
tra-indicated and  chloroform  anesthesia  alone  cannot  safely  be  maintained 
at  the  depth  necessary  totally  to  abolish  the  cough  reflex  for  anv  length  of 
time.     Cocain  or  morjihin  may  be  given  hypodermatically. 

Selection  of  tubes  for  the  particular  ease.  In  regard  to  the  sizes  of 
tubes  required  for  a  given  case,  it  may  be  stated  that  for  lower  trache- 
oscopy a  tube  8  mm.  x  20  cm.  will  be  required  for  adults,  and  5  mm  x  14 
cm.  for  children.  For  upper  .tracheo-bronchoscopy  a  tube  7  mm.  x  45  cm. 
will  be  needed  for  adults  and  3  mm.  x  20  cm.  for  infants.  In  older  chil- 
dren a  7  mm.  x  20  cm.  tube  may  be  used.  It  is,  of  course,  a  great  desid- 
eratum to  use  the  largest  possible  tube.  Fortunately  the  trachea  and 
bronchi  are  dilatable  so  that  the  tube  need  not  be  nuich  smaller  than  their 
diameter.  But.  of  course,  it  nnist  be  remembered  the  size  diminishes  with 
each  bifurcation.  When  a  bronclius  of  such  small  caliber  is  reached  that 
It  is  not  wise  to  push  the  tube  further,  a  smaller  one  should  be  introduced 


C  =  tf-. 


Fio  42. — Inner  bronchoscopic  tube,  for  insertion  throusb  a  larser  tube  wlicn  tlie 
la  Iter  has  reached  as  far  as  its  size  -will  permit. 

through  the  first.  This  inner  tube  (Fig.  42)  may  be  pushed  4  or  5  centi- 
meters further,  which  will  serve  to  reach  the  periphery  of  the  lung. 

For  instrinnentalion  it  is  always  of  great  advantage  to  use  the  largest 
possible  tube. 

Tracheotomy.  For  lower  bronchoscopy  the  tracheotomy  should  be  a 
low  line;  the  lower  the  better.  Xot  so  much  for  the  shortness  of  the  tube 
thus  rendered  possible,  but  because  the  chin  is  so  much  less  in  the  wa\'. 
When  necessary,  however,  it  is  feasible  to  tracheoscopize  through  the  high- 
est of  tracheotomy  woinids.  The  author  has  moie  than  nnce  tracheoscopi- 
cally  examined  the  trachea  through  a  thyrotomy  woiintl  that  did  not  ex- 
tend into  the  cricoid  cartilage. 

The  dangers  of  tracheotomy  may  be  minimized  by  attention  to  the 
following  details : 

The  technic  of  both  the  tracbtotimi}-  and  the  bronchoscopy  must  be  as 
near  absolute  asepsis  as  it  is  possible  to  make  it. 

The  patient,  diuMn^'  the  operation  and  for  12  hours  afterward,  nuist 


52  TRACHEOTOMY. 

be  kept  in  a  semi-Trendelenburg  position.    That  is  there  must  be  no  pillow 
and  the  foot  of  the  table,  and  later  the  foot  of  the  bed,  must  be  raised. 

The  tracheotomy  wound  must  not  be  stitched  except  perhaps  one 
stitch  at  the  extreme  upper  and  lower  angles.  T'he  tracheal  canula  should, 
if  possible,  be  abandoned  before  the  patient  leaves  the  warm,  moist  air  of 
the  operating  room.  The  wound  should  be  packed  with  gauze  w  rung  out 
of  mercuric  bichloride  solution  i  :50oo,  and  it  should  be  repacked  every  3 
hours.  Healing  should  be  allowed  to  take  place  from  the  bottom,  making 
sure  of  the  binding  together  of  the  li]is  of  the  tracheal  wound  by  fibrous 
tissue  before  the  more  superficial  portions  of  the  wound  are  allowed  to 
close.  If  this  be  not  done  fungating  granulations  from  uncovered  cartilage 
will  intrude  into  the  trachea  for  a  long  time  (see  Fig.  12,  Plate  11). 


Mt»a»»t(   iwc'ji.^  M-o.(0  Lt«"-.   ■B;wowot  «  wjiiTCN 
SCHEIE  LLUSTHAnNO  UPPER  TliACHEO- BRONCHOSCOTV. 


CHAPTER    V. 
Direct  Laryngoscopy  for  Diagnosis  and  Treatment. 

By  laryngoscopy  ordinarily  is  meant  the  examination  of  the  image  of 
the  larynx  as  seen  in  the  laryngoscopic  mirror,  by  whose  aid  the  interior  of 
the  larynx  is  illnmhiated. 

By  direct  laryngoscopy  is  meant  the  direct  inspection  of  the  interior 
of  the  larynx  without  reflection  of  the  image. 

In  order  to  do  this,  the  base  of  the  tongue  and  various  structures 
above  the  larynx  must  be  held  out  of  the  way,  and  the  head  must  be 
thrown  backward,  in  the  manner  described  in  the  preceding  chapter. 

In  general  it  may  be  stated  that  direct  laryngoscopy  for  diagnosis  and 
treatment  is  justifiable  in  all  cases: 

hirst,  where  these  ends  are  not  satisfactorily  attained  with  the  lar- 
yngeal mirror ;  and 

Second,  where  the  gravity  of  the  disease  renders  it  our  duty  to  use 
every  means  to  aid  our  patient. 

This  is  a  conservative  statement  based  upon  the  present  state  of  prac- 
tice. The  author  believes  the  near  fututre  will  see  the  tubular  speculum  in 
use  for  the  routine  examination  of  the  larynx  and  upper  end  of  the  esoph- 
agus. 

Dangers  and  Contr.v-indicatuixs 

It  may  be  stated  that  the  danger  of  direct  laryngoscopy,  per  sc,  under 
local  anesthesia  in  the  normal  larynx  is  nil ;  and  that  absolute  contra-indi- 
cations  are  few.  In  cases  with  extreme  dyspnoea  from  laryngeal  stenosis 
there  may  exist  indications  for  tracheotomy  without  the  laryngoscopy,  and 
it  is  in  the  hope,  well  founded,  of  obviating  this  operation  that  laryngos- 
copy is  attempted,  as  in  a  number  of  cases  in  the  author's  practice,  some  of 
which  are  herein  reported.  It  may,  therefore,  be  stated  that  the  danger 
arises  from  the  condition  calling  for  the  proceedure  and  not  from  the  pro- 
ceedure  itself.  This  is  predicated  upon  skillful  manipulation,  the  judg- 
ment as  to  when  to  stop  in  case  laryngeal  spasm  is  excited  by  the  presence 


DIFFICULTIES  IX  DIRF.CT  LARYNGOSCOPY.  55 

of  the  tube,  and  upon  the  abilit\  to  stab  the  traclica  instantly  in  case  the 
attempt  to  avoid  the  tracheotomy  proves  unsuccessful.  If  no  one  is  pres- 
ent who  can  do  this,  severe  dyspnoea  is  a  contra-indication.  The  gagging 
and  atteni]3ted  vomiting  excited  in  those  who  have  sensitive  throats  if  not 
controllable  by  cocain,  might  be  a  contra-indication  in  such  conditions  as 
aneurysm  and  those  with  hard  arteries  and  apoplectic  tendencies. 

The  author  has  never  yet  seen  a  case  in  which  he  deemed  it  unsafe 
directly  to  inspect  under  local  anesthesia  or  without  anesthesia,  the  larynx, 
save  those  that  demanded  an  immediate  tracheotomy  any  way  without  a 
direct  laryngoscopy.  Of  course,  a  general  anesthesia  introduces  a  risk  of 
its  own  in  any  case,  and  it  is  an  enormous  one  in  case  of  dyspnoea.  Should 
respiration  fail,  it  will  never  be  started  again,  unless  the  trachea  be  opened 
instantly.  Delaying  a  tracheotomy,  all  the  world  over,  at  the  present  day, 
is  a  common,  but  unjustifiable  and  unnecessary  risk  in  all  kinds  of  obstruct- 
ive dyspnoea. 

DlFFICULTIICS. 

Rigidity  of  the  neck,  in  elderly  subjects,  or  in  those  suffering  from 
various  vertebral  diseases,  tubercular,  rheumatic,  traumatic  or  congenital 
spinal  deformities,  is  at  times  a  serious  impediment  by  interference  with  a 
sufficient  degree  of  extension  of  the  head. 

Spastic  iiiiisciilar  cniitracfipus  in  young  vigorous  subjects  with  short 
thick  necks,  and  a  good  full  set  of  teeth  are  hindrances,  though  in  most 
instances  the  difficulties  disappear  under  general  anesthesia. 

Abiiudant  secretions  are  a  difficulty  with  ordinary  plain  tubes,  but 
with  the  author's  improved  drainage  system,  the  nurse  pumps  away  the  se- 
cretion as  fast  as  it  reaches  the  end  of  the  tube.  In  the  absence  of  this,  it 
is  necessary  to  interrupt  the  work  frequently  to  insert  the  drainage  tube  of 
the  aspirator,  and  armed  sponge  holders.  The  desire  to  expectorate  or 
swallow,  both  of  which  are  practically  impossible  with  the  mouth  gagged 
open,  is  the  cause  of  much  discomfort  to  the  patient  locally  anesthetized. 

Cough  would  be  one  of  the  greatest  difficulties  to  contend  with,  were 
it  not  for  the  fortunate  fact  that  it  is  usually  controllable  bv  local  and  gen- 
eral anesthesia. 

Respiratory  difheultics.  In  wi  irking  with  a  local  anesthetic  patients 
often  struggle  so  violently  to  get  up  that  the  examination  is  interrupted. 
This  is  due  in  some  instances  to  excitability  or  "nervousness,"  but  usually 
it  is  due  to  a  sense  of  suffocation.  .\  great  deal  of  trouble  and  difiicultv  will 
be  avoided,  if  the  patient  is  told  beforehand  that  he  will  feel  as  if  smother- 
ing, but  that  there  is  absolutely  no  danger,  and  that  he  must  have  confi- 
dence in  the  operator,  and  take  matters  quietly  and  easily.  The  sense  of 
suffocation  in  direct  larxngoscopy  may  come  from  spasm  of  the  larvnx 
from  the  presence  of  the  tubular  speculum,  or  from  covering  the  laryngeal 


56  DIFFICULTIES  IX  DIRECT  LARVXGOSCOPY. 

orifice  with  the  spatula  which  is  pushed  in  too  far,  going  behind  the  cri- 
coid cartilage.  In  either  case  withdrawing  the  speculum  slightly  relieves 
the  difficulty.  In  spasmodic  conditions,  cocain  should  be  reapplied.  If 
bronchoscopy  is  to  be  done,  the  bronchoscope  may  be  pushed  through  the 
cords  gently  without  injury  even  if  they  are  in  a  state  of  spasm,  though 
it  is  better,  usualh',  to  recocainize  and  wait. 

In  bronchoscopy  the  respiratory  difficulty  usually  comes  from  failure 
to  bring  one  of  the  breathing  orifices  of  the  tube  opposite  the  orifice  of  the 
lateral  branch  which  is  shut  oft'  by  the  tube 

In  patients  wearing  a  tracheal  canula  the  absence  of  glottic  breathing 
sometimes  renders  the  glottis  less  easy  to  find.  Patients  who  have  had 
previous  laryngeal  or  tracheal  disease  involving  the  cartilages,  or  who 
have  had  operations  performed  upon  the  structures  are  less  easy  to  exam- 
ine on  account  of  the  cicatricial  inflexibility. 

Abrasion  of  the  upper  Up  will  frequently  cause  interruption  of  the  pro- 
cedure by  the  patient  struggling  in  frantic  efforts  to  indicate  to  the  opera- 
tor the  cause  of  the  needless  pain. 

The  foregoing  and  all  other  difficulties  are  readily  overcome  bv  the 
skill  that  comes  from  practice  and  by  quiet,  orderly  procedure. 

It  is  always  wise  to  have  tracheotomy  instruments  prepared  for  everv 
direct  laryngoscopy  as  well  as  every  tracheo-bronchoscopy  or  esophagos- 
copy.  Not  that  they  are  likely  to  be  needed  except  in  the  dyspnoeic  cases, 
and  only  rarely  in  these,  but  it  is  a  good  safe  routine  to  drill  the  nurses 
into,  so  that  when  needed  no  time  will  be  lost.  If  this  be  not  done,  it  is 
quite  certain  that  when  needed  they  will  not  be  on  hand.  It  is  only  in  gen- 
eral narcosis  that  they  are  likely  to  be  required.  It  is  certain  that  in  serious 
respiratory  arrest  occurring  in  any  sort  of  case,  it  is  often  impossible  to 
start  respiration  without  tracheotomy.  Indeed,  it  should  be  the  routine  of 
every  operating  room  to  have  tracheotomy  instruments  sterile  and  readv 
for  every  case  of  any  kind  in  which  a  general  anesthetic  is  used. 

It  is  also  advisable  in  all  cases  of  direct  laryngoscopy  and  esophagos- 
copy  to  have  at  hand  a  small  bronchoscope  that  can  be  pushed  into  the 
larynx  in  case  of  respiratory  arrest  and  thus  save  the  necessity  for  trach- 
eotomy. If  the  operator  is  not  facile  at  jiassing  a  tube  through  the  glottis, 
the  tracheotomy  should  be  done  at  once. 

These  matters  are  mentioned  as  wise  precautions  that  any  operator  of 
experience  in  laryngeal  and  tracheal  diseases  will  understand  and  aopre- 
ciate.  As  a  matter  of  fact,  ordinarily,  direct  laryngoscopy  and  tracheo- 
bronchial or  esophageal  endoscopy  involve  no  risk  of  respiratory  arrest, 
and  it  is  hoped  that  the  mention  of  respiratory  arrest  will  not  induce  the 
inexperienced  to  regard  them  as  serious  procedures. 

"It  is  the  unexpected  that  happens."  might  be  parodied:  "It  is  the 
unprepared  for  that  happens,"  though  logically  unprovable. 


DIRECT  ]..4Ry\c:oscory  for  foriugx  bodies.      --.7 

Direct  Laio  ncoscoi-v  fow  I-okkicn  IVidiks. 
Foroio-n  bodies  in  the  larynx  are  in  all  cases  n..rc  promptly,  more 
safelv  an.lless  painfuUv  removed  by  direct  than  by  indn-ect  laryngosop) . 
vh    h    atter  .s  now  ob;olete  for  this  purpose.     Not  one  n,  a  dozen  cases 
:  a  sufficiently  tolerant  larynx  to  render  feasible  the  removal  o    a  fore.gn 
bodv  with  perfect  safetv  to  his  vocal  apparatus.     In  ahno.t  all  ms  ance. 
foreign  bocHes  can  be  removed  fron,  the  larynx  without  pan.  or  danger 
with  the  aid  of  the  tubular  speculum.     Tbe  exceptions  are  the  cases  m 
which  the  foreign  bodv  is  sharp  or  impacted,  or  in  those  havmg  a  danger- 
ous stenosis  from  acute  edema  or  the  presence  of  the  fore.gn  body  ,tsel  . 
In' these  cases,  tracheotomy  will  occasionally  be  necessary  though  much 
less  frequentlv  than  bv  any  other  method.     It  should,  of  course,  always  be 
prepared  for  as  a  matter  of  routine,  so  that  when  necde.l.  everythmg  will 
be  at  hand  for  c|uiet.  orderlv  procedure. 

The  technic  in  general  has  been  considered  in  a  previous  cliapter 
Cocain  anesthesia  is  sufficient  in  most  cases,  and  general  anesthesia  should 
be  especially  avoided   in   cases  where  there  is  the  slightest  dyspnoea  or 

''"''porceps  of  various  forms  and  a  hook  will  be  neede.l  for  the  best  re- 
sults in  .leahng  with  every  case  encountered,  though  m  most  cases  the  for- 
c;.  shown  in  Fig.  ..  will  be  sufficient.     In  cases  such  as  o    coii.s^ 
similar  Hat  objects  lying  crosswise  with  an  edge  in  each  ven  rid  .  a     gM 
angled  forceps  such  as  shown  in  Fig.  25.  but  with  thm  and  flat,    nsteaa 
of  punch  shaped  jaws,  will  be  best.     In  a  case  referred  to  the  author  by 
Dr   Crawford,  a  button  was  lying  not  in  the  ventricles,  but  cross.i.e  be- 
low the  cords,  fixed  bv  the  swollen  mucosa  (Fig.  7.  plate  I).     The  dii  d. 
a  bov  of  14  vears.  had  been  playing  with  a  hard  rubber  button  through  the 
holes  of  which  a  loop  of  string  had  been  tied.     While  jerking  thus  against 
his  teeth  the  center  of  the  button  pulled  out  and  the  button  was  aspirated. 
Violent  coughing  and  deep  cyanosis  followed  immediately  but  cleared  up 
and  recurred  e^'erv  few  minutes  for  several  hours.     After  one  of  these 
paroxvsms.  loud  whistling  breathing  was  noticed  and  continued  until  the 
patient  was  seen  bv  the  author  the  following  day.     There  was  shght  cyano- 
sis increased  bv  exertion.     Upon  attempting  an  examination  with  tlie  la- 
rvn-o«copic  mirror  the  child  became  so  cyanotic  that  it  was  feared  that  im- 
mediate tracheotomv  would  have  to  be  done.     Upon  direct  laryngoscopy 
under  cocain  anesthesia,  the  button  was  seen  in  the  position  shown.      It 
was  evident  that  the  button  had  been  fixed  by  the  swollen  mucosa  and  that 
the  whistling  came  from  the  passage  of  air  through  the  hole  m  the  center. 
A  hook  was  slipiied  down  flatwise  in  the  interarytenoid  space  until  below 
the  button,  then  turned  sidewise  and  brought  up  until  the  point  entered  the 
rao-o-ed  h-ilc  in  the  center.     The  button  was  then  pulled  against  the  end  of 


58       DIRECT  LARYXGOSCOPY  FOR  DISEASED  CONDITIONS. 

tlie  tulie.  turning  edgewise  as  it  came  upward.  Then  tube,  hook  and  but- 
ton were  pulled  out  as  one  piece.  The  child  made  a  good  recovery  with- 
out impairment  of  the  voice. 

As  illustrating  the  advantages  of  direct  laryngoscopy  in  a  very 
dyspnoeic  case  of  impacted  foreign  body  in  the  larynx,  the  following  case 
may  be  cited : 

Infant  G.,  aged  9  months,  a  croupy  cough,  with,  slight  elevation  of 
temperature.  A  diagnosis  of  membranous  croup  was  made  by  an  expert 
diagnostician,  and  antitoxin  given.  The  temperature  fell  to  normal  but 
the  croup\-  cough  persisted  for  a  month  and  other  advice  was  sought  by 
the  parents  who  suspected  that  a  piece  of  egg  shell  with  which  the  child 
had  been  playing  had  lodged  in  the  throat.  Dr.  ^loyer  and  Dr.  \\'echsler. 
who  each  saw  the  case  independently,  made  a  probable  diagnosis  of  foreign 
body  in  the  larynx,  in  spite  of  a  negative  radiograph  by  an  expert  Roent- 
genologist, and  referred  the  case  to  the  author  for  exploration.  On  ad- 
mission cyanosis  and  dyspnoea  forbade  a  mirror  examination,  and  even 
cocainization  was  not  attempted.  Upon  passing  the  tubular  speculum  a 
fragnnent  of  egg  shell  was  seen  on  edge  lying  between  two  edematous 
masses  as  shown  in  Fig.  6,  Plate  I.  It  was  quickly  removed  with  forceps, 
and  the  child  watched  all  night  in  anticipation  of  the  need  of  a  trache- 
otomy, which,  however,  was  not  required.  In  a  few  days  the  perichron- 
ditis  and  mucosal  ulceration  set  up  by  the  month's  sojourn  of  the  egg  shell 
in  the  infant  larynx  had  subsided.  This  case  points  several  valuable  les- 
sons. It  is  unwise  for  any  practitioner  persistently  to  reassure  patients 
or  their  relatives  with  the  statement  that  there  is  no  foreign  body  present 
and  that  if  present  it  could  do  no  harm.  Strange  as  it  may  seem,  it  is  the 
custom  with  many  practitioners  to  oppose  not  onl\-  a  search  for  a  foreign 
body  but  its  removal,  when  found.  TTiis  course  is  a  relic  of  the  days 
when  attempts  at  removal  were  crudely  and  blindly  made.  The  other 
lesson  tatight  by  this  case  is  that  when  symptoms  point  to  a  foreign  body, 
it  is  better  to  explore  even  if  the  radiograph  by  an  expert  Roentgenologist 
be  negative.     More  will  be  said  in  a  future  chapter  on  this  subject. 

Direct  Laryngoscopy  for  Diseased  Conditions. 

In  inalignaiit  diseases  of  the  larynx,  direct  laryngoscopy  is  of  the 
greatest  utilitv  for  diagnosis.  The  naked  eye  diagnosis  is  greatly  aided, 
and  the  taking  of  a  specimen  instead  of  being  a  difficult  uncertain  groping 
procedure,  is  done  with  a  precision  and  a  nicety  that  makes  direct  laryn- 
goscopv  a  necessary  procedure  with  the  laryngologist.  The  cup-shaped 
or  punch-like  jaws  should  be  used  in  the  forceps  for  this  purpose,  and 
where  possible  the  piece  bitten  out  should  include  both  pathologic  and  ap- 


DIRECT  LARYXCOSCOPy  I'OR  DISEASED  COXDI'I  lOXS.       •')» 

parently  normal  tissue;  in  oUkt  words,  it  should  be  taken  from  the  b  irder 
of  the  growth. 

The  diagnosis  of  paralyses  is  better  made  with  the  old  indirect  meth- 
od of  laryngoscopy,  for  the  pressure  of  a  laryngeal  speculum  interferes 
somewhat  with  motility  in  certain  individuals.  \\'ith  this  exceptiim.  how- 
ever, the  diagnosis  of  all  laryngeal  diseases  is  greatly  facilitated  by  direct 
laryngoscopy.  In  children,  indirect  laryngoscopy  is  often  difificult,  and  at 
times  it  is  impossible  to  see  beyond  the  epiglottis.  (  )f  course,  when  anes- 
thetized, indirect  laryngoscopy  is  easily  carried  out  in  children,  it  the 
tongue  is  drawn  out  with  a  piece  of  silk  worm  gut  passed  througli  it.  The 
great  disadvantage  is  that  most  diseases  of  the  larynx  in  children  are  ab- 
solute contra-indications  to  anesthesia.  Local  anesthesia  is  usually  suffi- 
cient for  direct  laryngoscopy.  \'ery  unruh^  children  \vill  have  to  be  held 
firmly,  as  the  procedure  may  terrify,  though  it  is  not  painful  in  the  )ciung. 
whose  tissues  are  always  yielding.  The  reflex  C(iughing  and  gagging 
make  it  seem  to  the  onlooker  a  desperate  procedure,  and  relatives  should 
always  be  excluded  from  the  room. 

For  the  treatment  of  malignant  disease,  endolaryngeal  methods  are, 
in  the  author's  opinion,  absolutely  contra-indicated  in  the  present  state  of 
our  knowledge.  Some  day  a  therapeutic  cure  will  he  discovered,  and 
should  that  c'u-e  be  by  topical  application  direct  laryngoscopy  will  1:)e  the 
method  of  applying  it.  tint  at  present,  direct  laryngoscopy  is  of  aid  cinly 
in  the  diagnosis. 

Benign  iicoplasins  oiler  a  wide  field  for  not  only  the  diagnosis  bat  for 
treatment  with  the  aid  of  direct  laryngoscopy. 

Papillomata  in  adults  may  be  removed  with  good  chances  of  com- 
plete cure,  at  a  single  operation.  The  serrated  jaw  forceps  (Fig.  22) 
should  be  used  for  pedunculated  growths,  following  with  the  cup-shaped 
jaws  (Fig.  24)  with  which  the  entire  base  should  be  bitten  out  along  with 
some  normal  tissue.  In  some  cases  the  lar\-ngeal  speculum  is  not  suffi- 
cient and  the  tracheoscope  will  have  to  be  passed,  as  the  growth,  though 
presenting  above  the  cords,  has  a  long  pedicule  springing  from  a  sub- 
glottic portion  of  the  larynx.  The  best  procedure  in  subglottic  cases 
often  is  to  push  the  tracheoscope  on  past  the  growth  and  then  tci  withdraw 
it  until  the  growth  drops  in  front  of  the  tube. 

When  springing  from  the  anterior  angle  of  the  lar\nx  at  or  above  the 
cords,  the  most  skillful  technic  is  necessary  to  extiq^ate  the  growth  by  di- 
rect laryngoscopy  under  local  anesthesia  in  an  adult.  In  a  young,  vigor- 
ous, muscular  adult,  all  the  anterior  cervical  muscles  are  thrown  into  a 
state  of  tetany  by  the  reflexes,  and  the  liyoid  bone  and  attached  tissues  do 
not  yield  readily  to  pressure  unless  relaxed  by  general  anesthesia.  The 
curved  jaws,   (Fig.  23)  turned  to  point  upw'ard,  are  very  convenient  for 


60       DIRECT  LARYNGOSCOPY  FOR  DISEASED  CONDITIONS. 

removing-  growths  from  the  anterior  angle,  or  hetter  still  the  punch  jaws 
( Fig.  25 ) .  For  other  locations,  intrinsic  and  extrinsic,  the  instruments 
of  Moslier.  (Fig.  5)  designed  for  the  upper  end  of  the  esophagus,  are 
convenient  for  use  through  the  laryngeal  speculum. 

Papillomata  in  children  may  be  very  readily  removed  from  any  por- 
tion of  the  larvnx.  and  usually  under  local  anesthesia.  They  are  almost 
certain  to  recur,  so  that  many  sittings  are  necessary.  In  one  case  a  girl 
of  four  years,  the  author  removed  recurrent  multiple  papillomata  twenty 
times  anil  the  end  is  not  yet  near.  Tracheotomy  is  not  necessary,  if  the 
growths  are  small,  but  should  always  be  prepared  for.  The  wearing  of  a 
trachc(itiim\-  canula  is  supposed  to  inhibit  growth  and  retard  recurrence. 
Thyrotoniy  is  absolutely  contra-indicated  for  pajMllomata  in  children,  and 
the  best  method  known  to-day  is  repeated  endoscopic  removal  with  or 
with(  )Ut  tracheotomy. 

(  )ther  benign  laryngeal  neoplasms  as  fibromata,  angiomata,  edema- 
tous pohpi.  lipomata,  chondromata,  cysts,  etc.,  are-  very  satisfactorily 
treated  tliror.gh  the  direct  laryngeal  speculum. 

Singers  nodes  are  also  amenable  to  local  direct  treatment. 

Larviii;cal  tuberculosis  occurring  as  a  complication  of  pulmonary  or 
general  tuberculosis,  or  in  the  form  of  a  local  lesion  as  lupus,  or  as  a  chronic 
tubercular  abscess  of  a  crico-arytenoid  joint,  may  be  treated  medically  and 
surgically  by  direct  laryngoscopy,  and  with  a  precision  possible  in  no 
other  wav  save  by  thyrotomy,  which  will  not  often  be  required  by  the  pa- 
tient of  the  facile  direct  laryngoscopist. 

Iiiflauiiuatory  diseases,  especially  in  their  edematous  phases,  have 
never  been  handled  with  the  facility  now  possible.  At  the  Eye  and  Ear 
Hospital,  in  a  number  of  very  severe  cases  which  ordinarily  would  have 
been  tracheotomized  at  once,  the  author  made  a  dozen  punctures  in  the 
edematous  tissues  in  less  than  a  minute  with  the  knife  (Fig.  29)  evacuat- 
ing the  serum  and  curing  the  cases  promptly  and  safely.  A  bronchoscope 
was  kept  at  hand  so  that  should  asphyxia  threaten,  it  could  be  pushed 
through  the  glottis  and  thus  relieve  the  dyspnoea  ;  but  the  necessity  did 
not  arise.  Alan\-  less  urgent  cases  have  been  quite  as  satisfactorily  dealt 
with. 

/;/  abscess  of  tlie  larynx ,  following  edematous  laryngitis  or  other 
■  acute  or  chronic  cause  may  be  evacuated  with  precision  and  without  risk 
to  local  structures  or  to  life. 

Cicatricial  Stenoses  of  the  larynx  consisting  of  fibrous  webs,  adhe- 
sions, and  cordal  synechise  when  not  complicated  by  defomiity  from  car- 
tilaginous necrosis,  are  best  treated  by  endoscopic  incision  of  the  cicatrices, 
followed  by  prolonged  intubation.  The  author  has  successfully  treated  a 
number  of  such  cases  following  typhoid  fever,  erosions  from  prolonged 


LARYSGIIAL  PARALYSES.  <il 

sojourn  of  fiircii;n  l)i)clics  and  intubation  tubes,  etc.  \\  iu-n  iiniluui^fil  in- 
tubation is  to  be  used  after  tbe  incisiiMi  of  cicatrices,  the  tul)e  should  be 
removed  everv  5  or  6  days  lest  concretions  on  the  tulx-s  lead  to  ulceration 
and  fresh  cicatrices.  This  is  less  likely  to  happen  with  hard  rubber  in- 
tubation tubes. 

Laryngctil  Paralyses.  For  the  galvanic  and  Faradic  treatment  of 
laryngeal  paralyses  the  author  has  devised  a  monopolar  electrode  (Fig.  43) 
with  which  applications  may  be  made  with  nicety  to  the  various  muscular 
groups  and  it  is  a  beautiful  sight  to  see  the  muscles  work  thus  at  the  ope- 
rator's will.  This,  of  course,  is  onlv  possible  in  recent  conditions  prior 
to  atrophic  change,  and  must  be  done  with  cautinn  in  untracheotomized 
cases.  In  a  case  of  bilateral  abductor  paralysis  sent  to  me  by  Dr.  F.  D. 
Johnston,  the  muscle  play  was  beautiful,  but  the  muscles  eventually  lost 
their  electro-excitability  after  going  through  an  increased  excitability, 
followed  by  a  period  in  wliich  they  showed  a  reaction  of  degeneration. 
This  case  had  been  previous!}-  tracheotomized  bv  the  author  for  dyspnoea. 
In  a  case  not  tracheotomized  due  caution  must  be  exercised. 

The  rules  and  indications  for  the  application  of  galvanism  and  Far- 
adism,  strenglh  of  current  and  nther  matters  are  not  within  the  scope  of 


E^ 


Fi(i.  4.". — .Mnii.niular  l.ii-yuiifal  elf  (-•trade  for  (iah  aiii.-iii  and   Fai-ailism. 

this  work.  Fndoscopic  applications,  of  course,  follow  the  satne  rules  as 
apply  to  applications  by  the  difficult,  uncertain,  indirect  method  with 
curved  electrode  and  laryngeal  mirror. 

The  technic  is  simple.  The  one  pole  (positive  or  negative,  as  de- 
sired) is  apjilied  with  a  "sponge"  electrode  held  Iiv  a  luirse  to  the  neck 
externally,  while  the  operator  touches  the  desired  piiiiit  with  the  monopolar 
endo-laryngeal  electrode  under  direct  inspection  through  the  tubular 
speculum.  A  hi-polar  instrument  has  also  been  used  bv  the  author,  en- 
abling the  use  nf  both  poles  within  the  larynx.  Its  application  is  not 
much  more  difficult,  but  it  has  not  \ielded  any  better  results  than  follow 
rnono-polar  endolaryiigeal  ap])lications.  In  all  forms  of  recurrent  paral- 
yses, the  external  electrode  should  be  aiijilied  on  the  course  of  the  recur- 
rent as  low  in  the  neck  as  possible. 

In  sensory  laryn(;cal  neuroses  as  anesthesia.  Iiyperesthesia,  and  pares- 
thesia the  local  application  of  the  Faradic  and  the  cnnstant  currents  are  of 
great  thera])eutic  value.  Tliey  can  be  applied  to  the  pyriform  fosss  in 
close  proximity  to  the  course  of  the  superior  laryngeal  nerve  with  the  elec- 


fi2  RETROGRADE  LARYXGOSCOPY. 

trode  (Fig.  43)  passed  through  llic  laryngeal  speculum.  In  paresthesia 
the  same  application  is  useful. 

For  the  a['pUcation  of  the  cautery,  electric  or  cheniicai.  the  tubular 
speculum  lends  itself  as  a  most  necessary  aid.  Personally,  the  writer's 
experience  is  not  very  favorable  with  these  agents,  however  applied,  but  if 
used  at  all.  it  should  be  by  the  direct  method.  P.e  the  apparatus  ever  so 
ingeniouslv  devised  and  the  operator  incomparably  facile,  the  indirect 
method  is  at  best  uncertain,  and  the  apjilication  is  apt  to  be  made  where 
not  wanted. 

Congenial!  icebs  of  the  larynx,  while  not  strictly  diseased  conditions, 
mav  be  considered  here.  They  are  quickly  and  accurately  dealt  with 
endoscopically,  using  the  straight  laryngeal  knife  (  Fig.  29)  and  making 
such  incisions  as  ma}-  be  planned  for  the  particular  case.  In  some  in- 
stances, it  may  be  necessary  practically  to  carve  out  and  form  a  cord  or  a 
pair  of  cords. 


r'ld.   44. — GahaiiO-eaiitory   electrode   for   use   lliroiigU   the   tiiliiilar   siieeuliim. 
RliTROGRADE    L.\RYXGOSCOPV. 

In  mam-  instances  valuable  information  can  be  obtained  by  looking 
upward  at  the  larvnx  from  below.  It  should  be  a  matter  of  routine  thus 
to  examine  everv  case  requiring  tracheotomy  for  laryngeal  obstruction. 
The  cords  mav  be  seen  to  move  beautifully  where  there  is  no  paralysis  or 
fixation.  The  lesions  of  inflammation,  syphilis,  tuberculosis,  typhoid 
fever,  diphtheria,  etc..  are  revealed.  \\'hile  these  are  not  so  often  infra- 
glottic  as  supra-glottic,  yet  they  occur  and  should  be  sought  for.  In  two 
instances  the  author  has  discovered  a  malignant  infiltration  that  had  es- 
caped indirect  laryngoscopic  observation  from  above  by  the  good  laryn- 
gologist  attending  the  cases.  Obviously  it  is  only  called  for  when  the 
tracheotomy  wound  is  low,  not  extending  to  the  thyroid  cartilage. 

The  method  is  simple.  A  short  tracheoscope  ( 5  mm.  x  14  cm.  for  a 
child.  8  mm.  X  20  cm.  for  an  adult),  is  inserted  in  an  upward  direction, 
after  cocainizing;  the  mucosa. 


CHAPTER  VI. 

Anatomy   of   the   Tracheo-Bronchial   Tree,  Topo- 
graphically, Radiographicaliy  and  Lndos- 
copically  Considered. 

An  absolute  essential  to  the  best  work  in  a  difficult  case  is  a  knowl- 
edge of  the  anatomy  of  the  tracheo-bronchial  tree  as  seen  from  the  inside 
in  the  living. 

For  this  purpose  the  anatomical  works  afford  little  help.  To  begin 
with  the  illustrations  are  upside  down  for  the  tracheo-bronchoscopist  work- 
ing on  the  recumbent  patient ;  and,  further,  the  older  works  are  in  some 
instances  absolutely  erroneous. 

A  brief  synopsis  is  all  that  comes  within  the  scope  of  the  present 
work.  For  further  anatomical  details  the  student  is  referred  to  the  ca- 
daver. Tlie  bri  mchoscope  has  opened  up  a  large  field  for  original  work 
in  practical  broncho-pulmonary  anatomy,  normal  as  well  as  pathologic. 

The  trachea  just  below  its  entrance  into  the  thora.K  deviates  slightly 
to  the  right,  to  allow  room  for  the  aorta.  At  about  the  level  of  the  second 
costal  cartilage  in  adults,  the  third  in  children,  the  trachea  bifurcates  into 
the  right  and  left  main  bronchi.  This  corresponds  to  about  the  fourth  or 
fifth  thoracic  vertebra,  the  trachea  being  elastic  and  displaced  by  various 
mo\'emcnts.  These  landmarks  are  of  ^/aluc  in  tlie  interpretation  of  radio- 
graphs. 

The  non-bran(-hcd  part  of  the  right  main  brnnchiis  is  steeper  and 
shorter  and  wider  than  its  follow  of  the  opposite  side,  and  is  praclicalh- 
the  continuation  of  the  trachea,  while  the  left  might  be  considered  as  a 
branch.  This  is  seen  in  Figure  45.  The  right  bronchus  gives  ofif  first 
the  superior  lobe  bronchus,  (SL),  then  the  middle  lobe  bronchus,  (ML), 
the  continuation  downward  being  the  inferior  lobe  bronchus  (IL),  Tlie 
superior  lobe  bronchus  is  the  only  bronchus  classed  as  eparterial :  that  is 
given  off  above  the  crossing  of  the  pulmonary  arteries.  .Ml  the  others 
come  off  below  the  crossing  and  are  classed  as  hvparterial. 


64 


TRACHEO-BROSCHIAL  TREE. 


TIk-  k-ft  main  hn melius  gives  off  first  the  superior  Inhe  lironehus 
(SL).  the  eontinuation  being  the  inferior  lobe  bronchus  (IL). 

The  bronchial  branches  are  classed  into  dorsal  and  ventral  groups, 
four  in  each  group.  This  is  by  no  means  constant.  An  occasional  anoni- 
oly  is  a  fifth  right  lironehus  sometimes  called  a  cardiac  bronchus.  The 
ventral  branches  are  usually  the  longer. 

As  just  mentioned,  the  bifurcation  of  the  trachea  is  at  the  level  of  the 
intervertebral  disc  between  the  fourth  and  fifth  dorsal  vertebne  :  and  the 
anterior  landmark  is.  in  adults,  the  second  right  chondro-sternal  articu- 
lation. In  a  child  of  2  vears.  on  account  of  the  more  nearly  horizi.mtal 
direction  of  the  ribs,  the  level  is  that  of  the  tliird  chondrosternal  articu- 
lation. \Mien  the  patient  is  between  two  years  and  adult  life,  the  point 
must  be  estimated  pro  rata. 


Fig.  4.J. — Traclii'u-liroiiiliinl   (n^e. 
LM.    Lffl    main    bronchus:     S  L.    SupciMdi'    \i<W    lu-oiieluis 
bronclui.s  :  1  L,  Infenor  lobe  bronchus. 


M  L.    Midillf    Iobc> 


The  bifurcation  is  usually  a  little  to  the  right  of  the  medium  line : 
about  half  way  between  the  vertical  center  line  of  the  sternum  and  its  right 
border.  This  varies,  of  course,  though  slightly,  with  the  position  of  the 
body  and  with  the  respiratory  movements. 

Tlie  deviation  of  the  right  bronchus  is  usually  about  ly .  and  its 
length  unbranched.  measured  from  the  bifurcation,  is  about  j.5  cm.  The 
deviation  of  the  left  bronchus  is  about  75°,  and  its  length  is  about  5  cm. 
These  angles  and  distances  laid  off,  upon  a  radiograph,  from  the  bifurca- 
tion as  indicated  by  the  landmarks  just  referred  to,  will  give  the  location 


TRACH EO-BKOX C H I AL  TRUE.  fi5 

of  the  first  branch  of  the  respective  main  bronclii.  These  are  the  land- 
marks most  important  radiographically,  and  for  the  lateral  plane,  they  are 
fairly  constant  and  very  satisfactory,  both  for  the  location  of  foreign  bodies 
and  diseased  areas  at  or  above  these  points.  For  localization  below,  they 
are  accurate  enough,  so  far  as  the  lateral  plane  is  concerned,  but  beginning 
with  the  first  branch  of  the  bronchi  below  the  bifurcation,  the  anteropos- 
terior plane  has  to  be  studied,  and  here  the  radiograph  is  not  of  much  aid 
on  account  of  the  distance  the  rays  must  pass  through  the  body  before 
reaching  the  plate,  in  attempting  to  take  a  lateral  view  of  the  thorax. 
However,  having  localized  a  foreign  body  or  diseased  area  in  reference  to 
the  tracheal  bifurcation  and  the  first  branch  of  the  main  bronchus,  we  will 
have  accomplished  all  that  is  needed  in  the  majority  of  cases,  and  in  in- 
stances of  involvement  of  even  the  deepest  bronchi,  we  will  have  reduced 
the  area  to  be  explored  to  very  narrow  limits.  Much  remains  to  be  ac- 
complished in  the  topographic,  radiographic,  and  endoscopic  study  of  the 
finer  subdivisions  of  the  bronchi  and  their  relation  to  peripheral  lung 
areas. 

Dimensions  of  the  traeliea  and  bronelii.  While  the  lumen  of  the  in- 
dividual bronchi  diminishes  as  they  bifurcate  the  sum  of  all  the  areas 
shows  an  increase  of  total  tubular  area  of  cross  section.  Thus,  the  sum 
of  the  areas  of  cross  section  of  tiie  two  main  bronchi,  right  and  left,  is 
greater  than  the  area  of  cross  section  of  the  trachea.  The  same  is  true 
of  each  bronchial  branching.  TTiis  follows  the  well  known  dynamic  law. 
The  relative  increase  in  surface  as  the  tubes  diminish  in  size  increases  the 
friction  of  the  passing  air,  so  that  an  actual  increase  in  area  of  cross  sec- 
tion is  necessary.  This  is  a  fortunate  thing  for  the  tracheo-bronchoscop- 
ist.  If  the  area  of  cross  section  were  cut  in  half  at  every  bifurcation  he 
would  not  get  as  near  the  periphery  as  he  now  does. 

The  dimensions  of  the  tracheo-bronchial  tree  may  be  epitomized  ap- 
proximately thus: 

Ailult  Male.  Female.  Chilil.  Infant. 

Diameter,  Trachea  14x20  mm.  12x16  mm.  SxlO  6x7. 

Length  Trachea 12.    cm.  Ic  .    cm.  6.  cm.  4.    cm. 

Right  Bronchus 2.5    "  2.5    "  2.    "         1.5    " 

Left  "  5.       "  5.      "  3.    "  2.5    " 

Upper  Teeth  to  Trachea 15.      "  13.  10.  9. 

Total  to  Secondary  Broiichus..32.  28.  19.  15. 

These  dimensions,  especially  those  given  in  the  last  line,  are  subject  to 
wide  variations,  and  are  only  approximate.  Tliey  were  taken  from  the 
cadaver.  The  diameters  do  not  take  into  account  the  dilatability  of  the 
trachea  and  the  amount  of  yielding  of  the  membranous  posterior  wall. 

When  the  foregoing  table  is  used  as  a  basis  for  the  selection  of  tubes, 
several  things  must  be  taken  into  consideration.  The  full  diameter  of  the 
trachea  is  not  available  for  upper  tracheo-bronchoscopy,  on  account  of  the 


66  TRACHEO-BRONChllAL  TREE. 

glottic  ajxM'ture  which  in  the  atUilt  is  an  cciuilatcral  triangle  measuring  ap- 
proximately 12x22x22  millimeters,  and  permitting  of  the  passage  of  a 
tube  not  over  ten  millimeters  in  diameter  without  risk  of  injury. 

As  to  length,  a  number  of  additional  centimeters  will  have  to  be  al- 
lowed. The  tube  must  project  above  the  upper  teeth  for  convenience  in 
working. 

As  to  the  length  of  tube  required  to  reach  below  the  first  branch  of  the 
bronchi,  tubes  of  45  cm.  and  even  50  cm.  will  occasionally  be  recjuired, 
though  these  very  long  and  necessarily  slender  tubes  are  usually  introduced 
inside  of  shorter  and  wider  ones.  In  many  instances,  a  view  is  had,  and 
probes  and  applicators  are  passed,  beyond  the  tube  so  that  a  full  length  is 
not  always  required. 

The  endoscopic  appearances  of  the  trachea  and  bronchi  are  interest- 
ing and  their  study  is  easily  accomplished.  The  appearance  of  the  inte- 
rior of  the  trachea  is  familiar  to  all  who  have  used  the  laryngeal  mirror. 
The  interior  of  the  bronchi  in  the  living  was  never  studied  until  the 
advent  of  the  bronchoscope. 

As  seen  in  the  bronchoscope  the  trachea  is  a  tube  slightly  flattened 
on  the  posterior  wall.  It  assumes  in  some  instances  a  greater  or  lesser 
tendency  to  an  elliptical  outline,  the  longer  axis  being  variously  placed. 
This  is  noted  more  particularly  in  twV)  locations.  The  upper  flattening  is 
in  the  cervical  portion  and  is  due  to  pressure  of  the  thyroid  gland.  The 
lower  one  is  intra-thoracic,  just  above  the  bifurcation,  and  is  due  to  the 
pressure  of  the  aorta.  This  flattening  is  rythmically  increased  with  each 
pulsation.  In  children  a  flattening  is  occasionally  noticed  due  to  pressure 
of  the  thyroid  gland.  In  mentioning  these  flattenings  reference  is  had 
only  to  conditions  strictly  within  the  limits  of  health.  All  these  changes 
of  outline  may  be  enormously  exaggerated,  even  to  entire  obliteration  of 
the  tracheal  lumen,  in  diseased  states. 

The  entire  trachea  is  often  seen  to  deviate  slightly,  usually  toward  the 
left,  and  occasionally  it  is  seen  to  deviate  first  in  one  direction,  then  in 
another,  making  a  slight  tendency  to  an  S  curve. 

The  mucosa  of  the  trachea  is  moist  and  glistening,  whitish  in  circular 
ridges  corresponding  to  the  cartilaginous  rings,  the  intervening  grooves 
being  reddish. 

At  the  bottom  of  the  trachea  a  white  shining  ridge  is  seen  to  divide 
the  trachea  antero-posteriorly  into  two  unequal  parts.  The  ridge  shades 
ofif  anteriorlv  and  posteriorly  into  two  reddish  triangles.  On  the  left  of 
the  ridge  is  the  slanting  orifice  of  the  left  main  bronchus,  and  on  the  right, 
its  larger  fellow. 

Passing  the  tube  down  the  right  bronchus,  a  view  is  presented  that 
differs  considerably  in  different  instances.     The  view  shown  in  Figure  11, 


TRACHEO-BROXCHIAL  TREE.  (57 

Plate  II,  is  from  a  water  color  drawing  of  the  right  hrcjiicluis  of  a  man 
25  years  of  age.  In  Figure  47  the  same  view  is  shown  without  color. 
At  the  right  (SL)  is  seen  the  orifice  of  the  fi.rst  branch,  the  upper  lobe 
bronchus.  Farther  down  anteriorly  is  seen  tlie  orifice  of  the  middle  lobe 
bronchus  (M).  At  the  left  (1)  we  look  into  the  depth  of  the  inferior  lobe 
bronchus  in  which  the  orifices  of  ventral  and  dorsal  branches  arc  seen. 

In  Figure  46  is  shown  a  bronchoscopic  view  of  the  left  bronchus  of 
this  same  man  (see  also  colored  Plate  II,  Fig.  10).  At  S  is  seen  the 
opening  of  the  superior  lobe  bronchus  while  th.e  entire  right  of  the  view 
shows  the  inferior  lobe  bronchus,  (really  the  continuation  of  the  main 
bronchus)  with  the  0[)enings  of  the  dorsal  and  ventral  Ijranchcs  in  more 
or  less  perspective.  It  will  be  noted  that  the  dorsal  and  ventral  branches 
are  not  given  ofl:'  opposite  each  other. 

Tlie  reference  letters  are  duplicated  in  the  dlustration  of  the  traclieo- 


FiG.  40.  Fig.  47. 

Bronchoscopic  views. 
Left  bronchus.  Right  bronchus. 

S.  Superior  lolic  bruiHii.w. 
S  L,  Superior  lobe  bronchus. 
I,  Inferior  lobe  bronchus. 
.M.   iliddle  lobe  broiu'hu>-. 

bronchial  tree,  Figure  45,  and  it  will  be  found  useful  to  study  these  to- 
gether. Not  that  they  are  to  be  taken  as  accurate  representations  of  con- 
stant anatomical  types,  but,  rather,  as  a  suggestion  as  to  how  the  tracheo- 
bronchial tree  is  to  be  studied  endoscopically.  The  illustrations  are  semi- 
diagrammatic. 

The  mucosa  of  the  bronchi  is  siniilar  to  that  of  the  trachea,  showing, 
however,  difil'erenccs  meriting  the  closest  scrutiny. 

The  movements  of  the  trachea  and  bronchi  as  observed  endoscopically 
in  health  and  disease  are  worthy  of  study,  of  -which  thcv  have  as  yet  re- 
ceived but  little.  The  normal  movements  may  be  classified  as  respiratory, 
pulsatory,  and  deglutitory.  The  two  former  being  rythmic  the  latter  be- 
ing noticed  occasionally,  and  only  in  lower  tracheoscopy.  Various  spas- 
modic and  transmitted  movements,  the  true  nature  of  which  has  not  yet 
been  demonstrated,  have  been  noted. 


CHAPTER   VII. 

Tracheo-Bronchoscopy  in  Diseases  of  the  Trachea 

and  Bronchi. 

The  brilliant  work  in  the  removal  of  foreign  bodies  has  led  to  the  im- 
pression that  tracheo-bronchoscopy  is  useful  for  this  only.  The  near  fu- 
ture, however,  will  see  the  bronchoscope,  and  even  more  the  tracheoscope 
and  tubular  speculum,  in  frequent  use  for  the  diagnosis  and  treatment  of 
diseased  conditions. 

The  diseases  of  the  trachea  and  bronchi  in  which  tracheo-broncho- 
scopy is  useful  may  be  divided  into  non-stenotic  and  stenotic.  All  cases 
of  stenosis  of  the  trachea  or  bronchi  justify  tracheoscopy,  upper  or  lower, 
as  may  be  indicated.  Of  the  non-stenotic  tracheal  diseases  it  is  chiefly 
those  in  which  no  satisfactory  view  is  obtainable  by  indirect  or  direct  lar- 
yngoscopy that  will  demand  tracheoscopy.  Of  non-stenotic  bronchial  dis- 
eases, many  that  cannot  be  said  at  the  present  day  to  demand  broncho- 
scopy, certainly  should  be  investigated  from  a  scientific  point  of  view,  as 
thus  our  knowledge  of  n:aii}-  bronchial  and  pulmonic  conditions  will  be  in- 
creased. 

Nou-stcnolic  morbid  conditions  of  the  trachea  and  bronchi  may  be 
tabulated  the  same  as  the  stenotic  diseases,  the  difference  being  chiefly 
of  degree. 

In  addition,  however,  there  are  a  number  of  diseases  rarely  associated 
with  stenosis.  Acu.te  and  chronic  inflammatory  conditions  of  a  mild 
type  usually  called  "catarrhal,"  objectionable  as  this  word  may  be,  will 
occasionally  demand  tracheoscopy  when  they  cannot  be  examined  by  in- 
direct or  direct  laryngoscopy.  Many  of  the  chronic  inflammatory  condi- 
tions will  require  tracheo-bronchoscopy,  not  only  for  diagnosis  but  for 
treatment  of  the  diseased  conditions  revealed.  Many  a  case  labelled  ner- 
vous cough,  and  allowed  to  annoy  the  patient  and  relatives  for  months  will 
be  found,  when  tracheo-bronchoscopized,  not  only  to  be  due  to  visible 
lesions,  but  to  lesions  that  can  be  cured. 


TRACHEO-BRONCHOSCOPY .  69 

In  a  case  of  this  kind  referred  lo  mc  by  Dr.  L.  W.  Swopc,  an  annoy- 
ing cough  of  several  months'  duration,  which  had  been  disturbing  rest  and 
producing  emaciation,  was  promptly  cured  by  six  direct  swabbing  appli- 
cations of  argentic  nitrate  to  a  non-specific  ulcer  discovered,  at  the  bifur- 
cation of  the  trachea,  by  tracheoscopy.  Ulcerations  more  deeply  seated, 
as  in  -inother  case  of  the  author's  at  the  bifurcation  of  a  bronchu';,  may 
be  discovered  and  treated. 

Qironic  tracheal  inflammation,  that  does  not  yield  to  treatment  based 
upon  indirect  laryngoscopy,  justifies  direct  laryngoscopy  or  tracheoscopy 
for  diagnosis  and  treatment.  The  same  may  be  said  of  ozena,  if  necessary 
for  diagnosis,  but  the  results  of  treatment  are  so  far  too  discouraging  to 
render  it  advisable. 

Pus  foci  near  the  periphery  of  the  lung  may  be  endoscopically  evac- 
uated or  may  be  localized  for  the  general  surgeon  to  attack  externally. 
Necessarily  the  cases  of  this  kind  of  tracheoscopic  possibilities  will  be 
those  in  which  communications  have  been  established  with  the  bronchi  of 
not  too  small  lumen.  Knowing  the  anatomy  and  the  normal  endoscopic 
appearances,  the  bronchoscopist  starts  his  tube  downward  from  the  trach- 
eal bifurcation,  noting  the  orifices  of  the  lateral  branches  as  they  are 
passed  until  a  bronchus  is  reached  in  which  disease  products  are  found, 
or  the  walls  of  which  give  ocular  evidence  of  disease,  as  inflammation, 
perforation,  granulation.  Specimens  may  be  taken  with  a  mop  or  aspi- 
rated into  the  accessory  drainage  tube.  As  orientation  is  not  easy,  a 
radiograph  ma}'  be  taken  after  blowing  in  bismuth  oxide  through  a  dry 
extra  drainage  tube.  Abscesses  of  the  lung  due  to  the  presence  of  a  for- 
eign body  may  be  thus  localized ;  and  if  the  foreign  body  cannot  be  re- 
moved endoscopically,  a  probe  passed  through  the  bronchoscope  into  the 
pus  focus  can  be  felt  through  the  lung  and  pleura  after  the  thoracic  wall 
is  opened. 

Stenoses  of  the  tracliea  may  be  classified  as  to  their  pathologic  mech- 
anism into  peri-tracheal,  muro-tracheal  and  endo-tracheal  conditions. 
Bronchial  stenoses  may  be  likewise  classified. 

In  considering  peri-tracheal  conditions  causing  stenosis  we  nnist  re- 
member that  the  trachea,  though  not  soft  as  compared  with  the  esophagus, 
is  not  a  rigid  tube.  It  is  very  readily  compressible,  and  is  subject  to  the 
encroachment  of  cervical  and  intra-thoracic  tumors.  Peri-tracheal  con- 
ditions producing  stenosis  include  glandular  hypertrophies,  glandular 
(lymphatic)  infiltrations,  aneurysm,  benign  and  malignant  tumors  of  ad- 
jacent tissues. 

The  great  frequency  of  stenosis  from  these  peri-tracheal  and  peri- 
bronchial conditions  was  not  known  until  the  development  of-  tracheo- 
bronchoscopy, as  in  many  instances  they  do  not  show  at  autopsy. 


70  1 RACHEAL  STENOSES. 

Of  glandular  livpcrtropliics  the  most  frequent  is  the  thyroid.  Struma 
intrudes  upon  the  tracheal  lumen  much  more  frequently  than  was  sus- 
pected until  tracheoscopy  was  extensively  practiced.  The  outline  of  the 
cross  section  of  the  tracheal  lumen  may  be  compressed  from  before  back- 
ward and  to  one  side  as  in  Figure  2,  Plate  I,  drawn  from  a  case 
of  goitre  in  a  man  36  years  of  age.  Or  it  may  be  compressed  in  addition 
from  behind  forward  by  the  retro-tracheal  portion  of  the  goitre  producing 
a  narrow  oval  slit,  the  so-called  "scabbard"  trachea. 

The  long  axis  of  the  ellipse  is  more  apt  to  be  at  an  angle  than  exactly 
in  the  transverse  plane  owing  to  the  relative  frequency  of  asymmetric 
Aruma. 

For  many  years  it  has  been  a  disputed  question  as  to  whether  the 
thymus  gland  can  compress  the  trachea.  It  has  been  the  author's  privi- 
lege to  demonstrate  tracheoscopicallv  the  error  of  Friedleben's  dictum, 
"Es  gicbt  kein  asthma  thyuiiciun:' 

This  case,  already  reported,  is  here  briefly  abstracted : 

Case  XXI,  Earl  L.,  aged  4,  was  admitted  for  dyspnoea  and  stridi^rous 
breathing,  increasing  since  the  sudden  onset  of  a  croupy  attack  six  weeks 
before.  Immediate  tracheotomy  by  the  author  failed  to  relieve  the  dysp- 
noea, but  the  passage  of  a  tracheoscope  relieved  it  completely.  Tlie  walls 
of  the  trachea  were  collapsed  from  before  backward  (Fig.  5,  Plate  I)  and 
they  opened  up  ahead  of  the  tracheoscope  like  the  cervical  esophagus,  and 
like  those  of  the  esophagus  they  tended  to  close  on  expiration.  One  of 
the  author's  long  tracheal  canulae  was  inserted  which  relieved  the  dysp- 
noea, and  later  held  the  trachea  open  while  the  little  finger  was  passed  be- 
hind the  sternum  into  the  anterior  mediastinum,  and  while  the  thymus 
gland  was  thus  brought  up  and  removed.  The  d\spnoea  never  recurred 
and  a  complete  cure  resulted,  without  ill  eiTect  from  the  absence  of  the 
gland.  (Fig.  48.)  A  radiograph  by  Dr.  Russell  H.  Boggs  shows  th; 
hypertrophied  gland  before  operation.    (Fig.  49.) 

This  case  demonstrates  the  diagnostic  value  of  tracheoscopy  in  com- 
pression tracheo-stenoses.  In  the  absence  of  his  long  tracheal  canulx  the 
author  has  more  than  once  used  a  tracheoscope  as  a  temporary  canula 
until  one  of  the  latter  of  proper  length  could  be  procured. 

Infiltrated  lymph  nodes  frequently  produce  stenosis  of  the  trachea 
and  bronchi.  Fig.  15,  Plate  II,  shows  compression  stenosis  of  the  right 
bronchus  thus  produced,  in  a  woman  of  26  years. 

Benign  and  malignant  tumors  of  the  peri-tracheal  tissues  produce 
compression  stenoses.  Such  a  case  is  illustrated  in  Fig.  9,  Plate  I,  wdiich  is 
drawn  from  the  case  of  a  man,  aged  60,  in  whom  an  epithelioma  of  the 
thoracic  esophagus  produced  a  compression  stenosis  of  the  trachea.  Later 
the  tracheal  wall  became  secondarily  involved  by  extension  of  the  infiltra- 


THYMIC  TRACHEOSTENOSIS. 


71 


Fig.   4S. — From  photograpli   of  patieut  4  months 
thymic  Iracheo-stei.osis  diagnosticaterl  tracheoscopically 


after   th.vmi'ctom.v.     Case   of 


TRACHEAL  STENOSES. 


Fli;.   V.) — Tliymic   traflieo-stenosis.     ItacHograpb   sUovviiig   gland   before   operatiou. 


TRACHEAL  STENOSES.  73 

tion.  AFediastinal  tumors  are  frequently  the  cause  of  tracheal  compres- 
sion. 

Aneurysm  is  a  not  infre(|uent  invader  of  the  trachea  and  bronchi,  as 
shown  in  Fig.  3.  Plate  I,  drawn  from  the  case  of  a  man  aged  50,  a  physi- 
cian. The  excursion  of  each  pulsation  is  shown  by  the  dotted  line.  This 
pulsatory  excursion  inward  of  one  portion  of  the  tracheal  wall  must  not 
be  confused  with  the  transmitted  cardiac  or  aortic  impulse  in  which  the 
entire  trachea  is  pushed  or  tugged  aside.  A  radiograph  of  this  case  is 
repro<luced  in  Fig.  50. 

In  Graves"  disease  the  transmitted  pulsations  may  simulate  aneurysm. 

Some  observers  have  seen  an  aneurysm  on  the  eve  of  bursting  into 
the  trachea. 

\'arious  peri-tracheal  and  peri-bronchial  inflammatory  conditions,  as 
Ludwig's  angina,  abscess,  etc.,  and  also  other  states  such  as  emphysema 
from  wounds  or  disease  of  the  upper  and  lower  air  passages  also  compress 
the  bronchial  and  tracheal  walls,  as  do  also  mediastinal  diseases  occa- 
sionally. 

^luro-trachcal  and  muro-bronchial  conditions  producing  stenosis  may 
be  enumerated  as : 

1.  jNlalignant  neoplasms. 

2.  Benign  neoplasms. 

3.  Specific    inflammations, 

a.  Syphilis, 

b.  Tuberculosis, 

c.  Glanders, 

d.  Typhoid  fever, 

e.  Diphtheria. 

4.  Inflanmiations, 

a.  "Catarrhal," 

b.  Irritative, 

c.  Traumatic, 

d.  Operative, 

e.  Post  operative. 

5..    Ulcerations  associated  with  the  foregoing  conditions. 

6.  Post  inflammatory  conditions  as  cicatrices,  hyperplasia  and  ad- 
hesions. 

7.  Vaso-motor  disturbances,  angio-neurotic  edema. 

Benign  neoplasms,  while  not  frequent,  are  seen  occasionally  by  the 
tracheoscopist  and  are  especially  adapted  to  endoscopic  treatment. 

Fig.  I,  Plate  I,  shows  a  papilloma  of  the  trachea  in  a  child  of  4  years, 
under  the  author's  care  at  the  Eye  and  Ear  Hospital. 

Of  the  specific  inflammations,  syphilis  is  by  far  the  most  frequent 


\ 


TRACHEAL  STENOSES 


Fig.  50. — Itadiuyraph  showiug  location  of  aneuryrsiu  tliat  liroiluced  tracheal  com- 
pression and  recurrent  paralysis. 


TRACHEAL  S'illXOSES.  75 

cause  of  stenosis,  in,  first,  its  edematous  and  later  in  its  cicatricial  stage. 
Fig.  8,  Plate  I,  is  a  tracheoscopic  view  of  post  syphilitic  tracheal  stenosis 
in  a  man  aged  24,  referred  to  me  by  Dr.  Frank  Trester  Smith. 

In  tvi)hrii(l  fever  as  in  -lil  of  the  conditions  enumerated,  the  tracheo- 
scope rnav  render  valuable  M-rvices.  By  this  it  is  not  meant  that  we  should 
go  through  the  wards  of  a  hospital  and  pass  the  tracheoscope  on  every 
case  of  typhoid  fever.  Bui.  to  illustrate,  a  number  of  the  cases  of  typhoid 
fever  in  the  Western  IViinsylvania  Hospital  that  required  tracheotomy 
were  examined  by  the  author  tracheoscopically  after  the  tracheotomy.  Le- 
sions were  discovered  that  would  be  invisible  by  any  method  other  than 
tracheoscopv. 

The  detailed  consideration  of  diseases  of  tlie  trachea  is  without  ths 
scope  of  this  work  and  the  subject  is  briefly  alluded  to  as  showing  the 
enormous  field  of  usefulness  open  to  tracheo-bronchoscopy. 

The  reader  who  is  interested  is  referred  to  the  bibliography  appended, 
and  in  particular  to  the  papers  of  Rodgers,  Simpson  and  Chiari,  on  trach- 
eal stenoses,  Theisen  uii  tumors  of  the  trachea,  and  Newcomb  on  diseases 
of  the  trachea,  and  to  I  lie  work  of  von  Schrotter  on  all  of  these  subjects. 

Cicatricial  tracheal  stenoses  offer  a  wide  field  of  usefulness  for  the 
tracheoscope.  These  cases  formerly  were  nften  very  difficult  of  diag- 
nosis bv  the  old  indirect  mirror  method.  A  tracheotomy  occasionally  aid- 
ed, but  ver\-  often  it  did  not.  Now  any  case  of  tracheal  stenosis  may  be 
positively  diagnosticated  by  direct  laryngoscopy  or  tracheoscopy. 

Cicatricial  tracheal  strictures  may  be  of  traumatic,  post-operative, 
post-nlcerative,  luetic,  tubercular  or  other  origin. 

As  examples  the  following  cases  may  be  reported : 

Case  \T]I.  Pcnn\  in  esophagus  2  months.  Erosion  through  into 
triichca.  Cicatricial  tracheal  stenosis.  Cure.  Seen  in  consultation  with 
Dr.  Sandels  and  Dr.  Ryal.  Raymond  B.,  aged  2  years,  had  a  penny  in  the 
esophagus  for  two  months.  (Fig.  51.)  For  two  weeks  after  the  acci- 
dent he  had  some  dysphagia  which  became  better,  as  increasing  cough  and 
dyspnoea  developed.  Cyanosis  was  so  great  on  admission  that  immediate 
tracheotomy  was  necessary.  The  penny  was  removed  from  its  ulcerated 
bed  by  the  esophagoscopic  method,  and  the  child  allowed  to  go  home. 
Three  weeks  later  he  was  brought  in.  quite  cyanotic  again,  and  upon  pass- 
ing the  tracheoscope  the  cicatricial  web  shown  in  Fig.  4,  Plate  I,  was 
seen.  A  complete  cure  resulted  from  prolonged  intubation  and  forci])le 
dilatation.     There  was  no  stenosis  of  the  esophagus. 

Remarks:  This  case  illustrates  the  danger  of  a  swallowed  foreign 
body.  The  ease  with  which  intubation  tubes  pass  through  the  alimentary 
canal  is  apt  to  lead  us  intn  the  error  of  supposing  that  anything  swal- 
lowed is  harmless,  especial])-  if  withnut  sharp  points  or  edges,  as  in  this 


76 


TRACHEAL  STENOSES. 


Fio.  51.— Radiograph  of  a  penny  in  esopliagus,  producing  traclieal 
two  months,  by  ulceration  through  the  tracheo-esophageal  wall. 


steno.sis  after 


TRACHEAL  SrnXOSES.  77 

case.  This  cliild,  if  iinrelicvi-d,  would  liavc  been  dead  oi  septic  ])neu- 
monia  in  a  few  days,  from  tlie  pus  which  was  being'  aspirated  down  the 
trachea  into  the  lungs. 

Fig-.  8,  Plate  I,  shows  a  cicatricial  web  [jroducing  partial  occlusion  of 
the  tracheal  lumen  in  a  man  aged  ;^2,  sent  to  me  by  Dr.  Frank  Trester 
Smith,  of  Chattanooga.  Tliis  stricture  was  incised  and  dilated,  with 
satisfactory  results,  though  a  laryngeal  stenosis  in  the  same  case  could  uot 
be  relieved. 

Cicatricial  strictures  of  the  bronchi  from  causes  similar  to  those  pro- 
ducing tracheal  stricture  are  occasionally  encountered.  Fig.  14,  Plate  II, 
is  a  good  example  of  this  condition,  in  a  man  of  33. 

Deviations  of  the  trachea  without  stenosis  are  frequent.  They  may 
occur  as  anomalies  or  as  a  displacement  by  peri-tracheal  tissues.  One 
very  interesting  case  of  this  kind  in  a  woman  of  23  years  was  referred 
to  me  by  Dr.  Ewing  W.  Day.  There  was  a  sharp  deflection  forward  to 
the  left,  then  backward  to  the  right.  The  axis  of  the  lumen  of  the  larynx 
was  from  above  downward  and  backward,  the  downward-forward-left  de- 
viation starting  abruptly  below  the  cricoid  cartilage.  There  was  marked 
ptosis  of  the  larynx,  the  lower  border  of  the  thyroid  cartilage  being  back 
of  the  sternum,  and  all  of  the  trachea  being  subglottic.  The  esophagus 
followed  the  same  deviations  as  the  trachea,  which  would  seem  to  indi- 
cate that  the  anomaly  was  not  congenital.  Two  cervical  ribs  were  pres- 
ent.    (Fig.  52.) 

Treatment.  In  many  instances  the  diagnostic  results  of  tracheo- 
bronchoscopy will  point  the  way  to  successful  general  therapy.  This  is 
occasionally  true  of  tuberculosis,  but  more  often  of  syphilis. 

The  local  treatment  of  stublxjrn  chronic  tracheitis,  especially  if  ulcer- 
ative, which  is  rare,  is  notably  successful. 

The  endoscopic  application  of  dilute  solutions  of  argyrol,  argentic 
nitrate,  balsam  of  Peru,  ichthyol,  and  iodine  gives  excellent  results.  In 
many  instances  these  applications  can  be  made  with  the  tubular  specidum 
under  local  anesthesia. 

Benign  growths  of  the  trachea  can  be  readily  removed  through  the 
tracheoscope. 

It  is  quite  feasible  to  remove  malignant  growths  originating  in  the 
tracheal  mucosa,  though  it  is  seldom  advisable  to  do  so,  on  account  of  the 
rapid  repullulation  afterward.  Adequate  removal  of  a  malignant  growth 
is  seldom  possible. 

The  tracheal  stenosis  due  to  fungating  granulations  in  the  trachea 
at  the  site  of  a  tracheotomy  wound  that  has  been  allowed  to  heal  at  the 
skin  before  the  trachea  has  healed,  may  be  very  promptly  cured  bv  the 
endo-tracheal  application   of  a   saturated   solution  of  resorcin.     Fig.    12, 


78 


STRICTURILS  OF  THll  TRACHEA. 


Plate  II,  represents  such  a  case.  Of  course,  a  better  plan  is  not  to  allow 
such  a  condition  to  occur,  but  unless  carefully  watched,  internes  are  very 
prone  to  permit  it  to  happen. 

Strictures  of  the  larynx  and  upper  trachea  are  best  treated  by  thy- 
rotomy,  thyro-tracheotomy,  or  by  dilation  with  tupelo  tents  followed  by 
prolonged  intubation.  In  one  case,  (Fig.  4,  Plate  I,)  a  high  tracheal 
stricture,  due  to  the  erosion  of  a  foreign  body  through  from  the  esoph- 
agus, was  dilated  with  an  extubator,  and  treated  by  prolonged  intuba- 
tion, with  a  result  of  perfect  cure. 

Strictures  of  the  cervical  portion  of  the  trachea  associated  with  loss 
of  cartilage,  are  probably  best  treated  by  tracheoplastic  surgery,   which 


Fig.  52. — Cervical  ribs  in-csent  iu  a  case  of  deviaUU  trachea  and  larynsoptosis. 

substitutes  some  rigid  material  for  the  lost  cartilage.  Such  methods  are, 
however,  strictly  limited  to  the  cervical  trachea.  P)elow  the  sternal  notch 
only  endoscopic  methods  are  available.  Some  excellent  results  have  been 
recorded. 

The  tracheal  cases  recjuiring  treatment  are  those  in  which  the  strict- 
ure is  so  small  as  to  interfere  with  respiration.  In  the  bronchi  the  cases 
requiring  treatment  are  those  in  which  there  is  interference  with  the  pass- 
age in  and  out  of  the  respiratory  current,  and  with  the  escape  of  secre- 
tions. This  condition  is  recognized  by  bronchoscopy  and  by  auscultation 
and  percussion. 


DIL.IT.ITJOX  OP  BROXCfU.lL  STRICTURE. 


79 


For  dilation  of  a  bronchial  stricture  the  most  practical  method  is  von 
Schrotter's.  Obviously  it  is  not  adapted  to  the  trachea.  \Mth  forceps, 
through  the  bronchoscope,  a  laminaria  tent  (1.5  cm.  to  2.5  cm.  in  length, 
4  to  7  mm.  in  diameter)  is  inserted  in  the  stricture  and  allowed  to  remain 
for  25  minutes,  during  which  time  the  thread  attached  to  the  tent  is  al- 
lowed to  hang  out  the  mouth.  The  tent  is  then  removed  and  a  metallic 
tube,  like  Fig.  53,  is  inserted.  The  tubes  used  by  von  Schrotter  were  of 
aluminum,  though  he  also  used  German  silver  and  iron,  because,  being 
more  dense,   they   cast   denser   shadows,   enabling  a   better   radiographic 


Fin.  53. 


Fir..  .i6. 


Fig.  54. 


FiCi.  5:1. — von   Schriittoi's  bronchial   iiilubatiou    Uil)e. 
Fig.   54. — voii   SchriUter's  brouchial   iulubatiou   tiilie   aud   mauilriu. 
Fir,.  5.5. — von  Schriittef'.s  iracheo-bronohial  clilating  tnbe  and  end  of  special  bron- 
cbo.-^cope  for  introduction. 


watch  to  be  kept  on  the  position  ol  the  tube.  The  sizes  used  were  from 
3  to  10  mm.  in  diameter,  and  10  to  25  mm.  in  length,  and  the  weight  in  some 
instances  was  as  much  as  4  grams.  The  shape  and  the  encircling  ridges  pre- 
vent expulsion  of  the  tube  by  coughing.  In  dilation  of  strictures  of  the 
trachea,  a  tube  with  a  bail  to  which  a  thread  was  attached  was  used,  tlie 
thread  being  long  enough  to  come  out  of  the  mouth  or  tracheotomy 
wound.  The  dilating  tubes  were  inserted  without  the  mandrin  used  in 
earlier  cases  (Fig.  54),  using  instead  a  bronchoscojje  with  a  dilated  end 
into  which  the  end  of  the  dilating  tube  telescoped,  being  held  in  place  bv 
the  thread  held  taut.      (Fig.  55.) 

The  author  has  devised  an  attachment  for  the  forceps  bv  which  tents 
may  be  placed.    (Fig.  25.) 


CHAPTER    VIII. 

Tracheo-Bronchoscopy,  Upper  and  Lower,  for  the 
Diagnosis  and  Lxtraction  of  Foreign  Bodies. 

General  Considerations.  Since  Killian  startled  the  medical  and  sur- 
gical world  with  the  announcement  of  his  removal  of  a  foreign  body  from 
a  bronchus  by  means  of  forceps  passed  through  a  straight  tube  introduced 
through  natural  passages,  the  crude  and  dangerous  blind  groping  in  the 
trachea  and  bronchi  for  foreign  bodies  with  forceps  introduced  through  a 
tracheotomy  wound  has  in  enlightened  circles,  gradually  given  way  to 
exact  methods  associated  with  little  risk.  It  is  not  meant  that  the  trach- 
eotomy wound  has  been  altogether  dispensed  with,  but  instead  of  groping 
in  the  dark,  the  foreign  body  is  now  found  and  seized  under  the  guidance 
of  the  eye. 

The  relative  adz'isabilify  of  upper  and  lozcer  broncJwscopy.  Save 
where  the  breathing  is  bad,  it  is  rarely  necessary  to  open  the  trachea  for 
tracheoscopy.  For  bronchoscopy,  however,  the  mechanical  manipula- 
tions of  entering  the  tertiary  and  even  the  secondary  bronchi  are  slightly 
more  difficult  through  the  natural  passages.  So  far  as  seeing  is  con- 
cerned, if  unilluiiiinated  tubes  are  used,  it  will  be  found  that  the  length  of 
tube  required  makes  it  much  more  difficult  sufficiently  to  illuminate  the 
object.  Ingals  states  that  upper  bronchoscopy  is  rarely  satisfactory  in 
children  under  3  years  of  age.  If  a  bronchoscopist  of  his  experience 
finds  it  unsatisfactory,  the  inexperienced  will  find  it  useless. 

\Mth  the  light  carrier  instruments,  however,  a  foor  more  or  less  of 
tube  makes  no  difiference,  if  the  observer's  eye  be  normal.  The  object, 
whether  one  foot  or  two  feet  away,  is  always  illuminated  with  the  same 
brilliancy,  while,  with  unilluminated  tubes,  the  intensity  of  the  light  dimin- 
ishes as  the  distance,  ^^'ith  a  properly  adjusted  headlamp  and  a  high 
polish  on  the  interior  of  the  tubes,  the  loss  is  not  as  the  square  of  the  dis- 
tance, for  the  rays  are  nearly  parallel. 


TRACHEO-BRONCHOSCOPY  FOR  FOREIGN  BODY.        81 

After  a  prolonged  upper  bronchoscopic  examination,  tiie  larynx  will 
show  some  irritation,  and  hoarseness  will  usually  persist  for  some  hours 
or  days,  but  if  no  actual  traumatism  of  the  cords  has  occurred,  the  voice 
is  perfectly  regained  at  the  end  of  a  week.  Even  if  some  traumatism 
has  occurred  the  voice  ultimately  recovers.  In  one  case  reported  by 
Nehrkorn,  tracheotomy  was  required  for  post-bronchoscopic  edema,  pro- 
duced by  a  two-hour  examination.  Von  Schrottcr  also  reports  a  case  of 
severe  laryngeal  edema.  In  general,  therefore,  it  may  be  stated  that  it  is 
unwise  to  persist  too  long  in  an  ujiper  bronchoscopy.  The  added  risk  of 
a  tracheotomy  is  less  than  the  risks  of  prolonging  the  anesthesia,  prolong- 
ing the  shock,  and  prolonging  the  abolition  of  the  cough  reflex.  The 
possibility  of  being  ultimately  compelled  to  resort  to  a  tracheotomy  any 
way,  either  from  unsuccess,  or  because  of  edema  of  the  larynx,  should  be 
borne  in  mind.    Edema  is  unlikely  if  a  small  tube  be  used. 

In  each  particular  case,  the  operator  will  weigh  the  personal  equation 
of  himself  and  his  patient  in  arriving  at  a  decision. 

Indications. 

Tracheo-bronchoscopy  is  indicated  in  any  case  in  which  the  presence 
of  a  foreign  body  in  the  trachea,  bronchi,  or  lungs  is  suspected.  It  is  not 
wise  to  hesitate  because  of  a  lack  of  certainty  of  its  presence. 

Professional  opposition  to  this  view  will  be  rarely  encountered  in  these 
days  of  safe  and  easy  tracheo-bronchoscopy.  Occasionally  a  relic  of  the 
old  days  of  dangerous,  and  usually  fruitless,  fishing  with  hooks  and  for- 
ceps introduced  into  the  trachea  and  bronchi  through  a  tracheotomy 
wound,  will  crop  out  in  the  form  of  an  opinion  that  an  expectant  plan  of 
treatment  is  indicated,  at  least  for  a  time,  if  not  indefinitely.  This  op- 
position will  arise,  in  three  classes  of  cases : 

1.  Those  cases  in  which  tlic  history  is  corroborated  by  the  Roentgen 
ray. 

2.  Those  in  which  it  is  corroborated  by  the  symptoms  or  the  physi- 
cal signs. 

3.  Those  in  which  it  is  not  corroborated  at  all. 

It  is  the  author's  opinion  that  in  ail  three  of  these  classes  of  case 
tracheo-bronchoscopy  is  indicated. 

It  has  seemed  more  convenient  to  consider  the  prognosis  of  the  ex- 
pectant plan  under  the  head  of  "Dangers." 

Results. 

Of  94  cases  of  tracheo-bronchoscopy,  upper  and  lower  for  foreign 
bodies,  collected  statistically  for  the  author,  the  corpus  delicti  was  found 
and  extracted  in  78  or  85.1  per  cent. 


82  DANGERS  OF  TRACHEO-BRONCHOSCOPY. 

The  cases  of  failure  were  those  in  which : 

I.  Inorganic  substances  as  pieces  of  kernels  of  nuts  or  gram,  beans 
and  the  like  had  swollen  and  become  impacted  and  buried  in  a  minute 
bronchus ;  or,  2.  In  which  there  was  a  stricture  above  the  site  of  lodg- 
ment ;  or,  3.  In  which  there  were  such  grave  symptoms  (present  before 
operation)  that  the  procedure  had  to  be  abandoned. 

CONTRA-INDICATIONS. 

Tlie  author's  views  are  rather  radical  on  the  subject,  but  he  does  not 
consider  anything  an  absolute  contra-indication  to  tracheo-bronchoscopy 
in  a  patient  known  to  have  a  foreign  body  in  the  trachea  or  bronchi,  as 
the  patient  is  very  much  safer  without  the  foreign  body  than  with  it,  no 
matter  what  the  condition  may  be.  Of  course,  should  there  be  doubt  as 
to  the  presence  of  the  foreign  body,  it  may  become  a  question  as  to  wheth- 
er the  procedure  would  be  justifiable  in  case  of  serious  diseases  such  as 
mentioned  under  the  general  subject  of  contra-indications. 

D.VNGERS. 

The  dangers  of  tracheo-bronchoscopy  in  general  have  been  consid- 
ered in  a  previous  chapter,  and  they  are  but  little  more  than  those  of 
anesthesia. 

Before  the  days  of  tracheo-bronchoscopy  the  physician  was  confront- 
ed with  the  problem  of  comparing  the  dangers  of  removal  with  those  of 
leaving  the  foreign  body  to  nature.  To-day  when  endoscopy  has  reached 
such  a  high  degree  of  perfection,  the  dangers  of  removal  are  exceedingly 
slight,  while  the  dangers  of  doing  nothing  are  great.  This  subject  is 
gone  into  more  fully  on  a  subsequent  page. 

Pneumonia  and  bronchitis  when  tliey  occur  are  far  more  likely  the 
result  of  the  condition  calling  for  the  tracheo-bronchoscopy  than  of  the 
procedure  itself. 

Ingals  reports  two  deaths  of  obscure  pathologic  mechanism.  One 
occurred  3,  the  other  6,  hours  after  the  successful  removal  of  the  foreign 
body.  He  is  unable  to  explain  it  but  suggests  the  possibility  of  its  being 
due  to  the  application  of  adrenalin  and  cocain.  so  close  to  the  vagus 
nerve :  or  possiblv  to  the  chloroform,  though  this'  seems  doubtful  as  the 
anesthesia  was  of  short  duration.  He  also  suggests  the  possibility  of 
secondary  surgical  shock. 

Xchrkorn  and  von  Shrotter  each  report  a  serious  laryngeal  edema, 
requiring  tracheotomy  after  upper  bronchoscopy.  This  edema  is  an  ele- 
ment of  danger  if  the  patient  is  discharged  immediately  after  extraction. 
Kept  in  the  hospital  there  is  no  danger  other  than  that  of  tracheotomy, 
should  this  become  necessarv. 


DANGERS  OF  TRACHliO-BROSCHOSCOPY.  88 

The  risk  of  lower  bronchoscopy  indc])endcnt  of  that  of  the  trache- 
otomy is  exceedingly  slight  if  done  gently  and  at  once  after  the  trache- 
otomy. If  delayed  until  the  tracheal  wound  becomes  infected,  the  danger 
of  carrying  in  septic  materia!  increases  the  risk  materially.  In  lower 
tracheo-bronchoscopy,  the  risk  of  tracheotomy,  independent  of  the  condi- 
tion calling  for  it,  is  not  over  2  per  cent.  Tracheotomy  here  must  not  be  con- 
sidered in  the  same  light  as  when  done  for  diseased  conditions.  TTie 
latter  have  an  extra  risk  in  the  primary  disease  and  in  the  usual  postpone- 
ment of  tracheotomy  until  the  respiratory  and  cardiac  centers  are  poisoned 
with  carbonic  acid,  and  the  resisting  power  of  respiratory  and  other  or- 
gans is  dangerously  weakened. 

One  danger  that  can  be  avoidctl  is  putting  tracheotomy  off,  until  the 
patient  has  ceased  to  breathe.  Then  a  moment's  delay  in  the  opening  of 
the  trachea  may  be  fatal  through  cardiac  arrest.  Respiratory  arrest  is  not 
dangerous  after  the  trachea  is  opened,  but  cardiac  arrest  is  usually  fatal. 
Respiration  often  cannot  be  started  unless  the  trachea  be  opened.  All  of 
these  dangers  are  avoided  by  preliminary  tracheotomy  and  lower  bron- 
choscopy. The  operator's  ability  to  stab  the  trachea  in  a  moment  when 
necessary  will  govern  the  risk.  In  a  few  of  the  author's  earlier  cases  of 
tracheoscopy,  tracheotomy  had  to  be  done  to  start  respiration  which  had 
stopped  apparently  from  respiratory  inhibition. 

The  hints  given  under  tracheotomy  if  followed  will  minimize  the  risks 
of  opening  the  trachea. 

Tracheal  varicosities  might  be  an  element  of  danger  did  they  exist 
in  a  foreign  body  case.  The  author  has  seen  several  instances  of  these 
lesions  unassociated,  however,  with  a  foreign  body.  Should  they  exist 
they  are  readily  seen  and  injury  to  them  readily  avoided  by  careful  manip- 
ulation of  the  tube. 

The  dangers  of  leaving  the  foreign  body  alone,  in  these  days  of  per- 
fected endoscopic  technic  do  not  merit  lengthy  consideration.  But  as  the 
relative  gravity  of  prognosis  will  arise  in  nearly  every  case,  and  occasion- 
ally a  relic  of  the  days  of  blind  groping  in  the  dark,  will  be  encountered 
in  opposition  to  tracheo-bronchoscopy,  the  dangers  of  the  "let  alone"  plan 
require  mention.  They  are,  briefly,  bronchitis,  bronchiectasis,  pneumonia, 
abscess,  gangrene,  cirrhosis,  pneumothorax,  and  possibly  tuberculosis. 
The  dangers  are,  therefore,  immediate  or  more  or  less  remote. 

The  degree  of  danger,  of  course,  varies  with  the  nature,  shape  and 
size  of  the  foreign  body,  its  position  and  the  condition  of  the  patient. 

The  shape  and  size  will  determine  the  depth  of  penetration  and  the 
probability  of  excluding  air  from  the  pyramid  of  lung  tissue  supplied  by 
the  occluded  tube.  Rounded  objects  are  particularly  prone  tighth-  to  fit 
a   bronchial    tube,   excluding   air   and   producing   gangrene    and    abscess. 


84  FOREIGN  BODIES  IN  THE  BRONCHI. 

Rough  or  pointed  objects  are  prone  to  cause  trauma  either  by  being 
coughed  back  and  forth  or  by  erosion  from  a  prolonged  sojourn  in  one 
position.  Either  of  these  conditions  is  ant  to  be  associated  with  infection, 
and  prolonged  irritation  ending  in  fatal  exhaustion.  Occasionally,  an 
abscess  may  discharge  spontaneously  into  a  bronchus,  the  foreign  body 
being  also  expelled  in  some  instances,  in  others,  not. 

Inorganic  substances  are  prone  to  swell,  macerate  and  decay,  usually 
causing  sepsis.  The  cooked  kernels  of  nuts,  especially  peanuts,  may,  as 
shown  by  Claytor,  macerate  in  about  a  month  sufficiently  for  the  pulp  to 
be  coughed  up.  During  this  time,  the  risks  of  bronchitis,  pneumonia,  and 
gangrene  and  sepsis  are  run.  Kernels  of  nuts  and  grain,  if  uncooked,  do 
not  macerate  sufficiently  to  be  coughed  up  and  their  swelling  fixes  them, 
so  that  they  are  not  dislodged  by  coughing  unless  they  slough  out. 

In  regard  to  sepsis,  there  are  two  factors  to  be  considered.  The  in- 
fection carried  down  with  the  foreign  bod\-.  as  for  instance,  a  decayed 
tooth ;  and  infection  by  organisms  occasionally  present  in  the  trachea  and 
larger  bronchi.  The  latter  are  the  least  to  be  feared.  Several  instances  of 
the  former  variety  of  infection  have  fallen  under  the  author's  observation. 
One  was  that  of  a  girl,  12  years  of  age^  who  had  aspirated  into  her  right 
lung  part  of  a  carious  incisor  broken  off  in  a  fall.  The  author's  urgent 
advice  of  immediate  bronchoscopy  was  opposed  by  the  family  physician, 
who  had  many  years  before  seen  a  death  from  blind  fishing  through  a 
tracheotomy  wound ;  and  subsequently,  a  recovery  from  the  "let  alone" 
method.  The  child  who  had  aspirated  the  tooth  died  of  septic  pneumonia 
about  a  week  after  the  accident. 

In  the  prognosis  of  aspirated  bodies  we  must  consider  the  possibility 
of  asphyxia  from  loosening  of  the  foreign  body  and  its  being  cast,  by 
coughing,  violently  up  against  the  subglottic  portion  of  the  larynx  and 
thus  causing  asphyxia  from  spasm ;  and  also  the  possibility  of  its  causing 
asphyxia  by  being  fixed  in  the  upper  portion  of  the  air  tract. 

It  is  exceedingly  rare  for  a  foreign  body  larger  than  a  millimeter  or 
two  in  size  to  become  encysted. 

The  first  24  hours  is  the  period  during  which  expulsion  is  most  likely 
to  occur,  if  at  all.  By  the  end  of  that  time  it  is  so  buried  in  the  swollen 
mucosa  that  it  is  seldom  expelled  until  after  sloughing  has  occurred. 

Statistics  are  against  the  "let  alone"  method.  Roe  collected  1417 
cases  of  foreign  body  in  the  air  passages,  in  which  no  extraction  was  at- 
tempted. There  was  a  mortality  of  27  per  cent.  It  may  be  argued  that 
these  statistics  do  not  include  many  cases  in  which  a  small  object  was  in- 
haled and  shortly  thereafter  coughed  up  again.  In  the  author's  opinion, 
this  is  fully  counterbalanced  by  the  numerous  cases  where  a  small  child, 
unable  to  talk,  or  forgetting  to  tell  of  it,  has  aspirated  a  small  foreign 


svMrroMS  of  porrign  body.  85 

body  and    died   of   pneumonia  or  other  complication,   the   true  cause  of 
which  never  was  suspected. 

Of  94  cases  of  bronchoscopy,  upper  and  lower  together,  collected  for 
the  author,  9  died,  making  a  mortality  of  9.6  per  cent.  Eliminating  six 
that  were  in  bad  condition  and  jjrobably  would  have  died  without  opera- 
tion, the  mortality  may  be  placed  at  3.2  per  cent.  Tlie  author  would  feel 
inclined  to  place  it  at  less  than  this  were  it  not  for  two  mysterious  deaths 
reported  bv  Ingals,  where  in  3  and  6  hours  respectively,  after  removal  of 
a  foreign  body  the  patient  unexplainably  sank  and  died. 

Summing  up,  the  prognosis  of  tracheo-bronchoscopy  is  good  if  the 
operation  be  not  postponed  until  the  patient's  condition  has  become  serious. 
In  cases  where  the  general  condition  is  serious  the  prognosis  is  not  so 
good  as  in  cases  in  better  condition,  yet  the  ultimate  prognosis  is  better 
with  the  operation  than  without. 

Other  things  being  equal,  the  prognosis  is  the  better  the  sooner  the 
foreign  body  is  extracted. 

In  conclusion  the  author's  opinion  is  that  we  do  full  justice  to  our 
patients  when  we  tell  them  that  while  the  foreign  body  may  be  coughed 
up,  the  chances  of  this  are  remote  and  it  is  very  dangerous  to  wait;  and 
further,  that  the  difficulty  of  removal  increases  with  each  hour  the  body  is 
allowed  to  remain. 

Symptoms. 

Cough.  This  is  the  most  constant  symptom  of  foreign  body  in  the 
air  passages.  It  appears  as  an  immediate  symptom  in  the  effort  to  pre- 
vent the  entrance  of  the  body  at  the  laryngeal  orifice,  and  later,  in  more  or 
less  paroxysmal  efforts  to  rid  the  air  passages.  Later  still  cough  is  pres- 
ent from  the  inflammatory  reaction  to  the  irritating  presence  of  the  in- 
vader. This  later  cough  is  more  apt  to  be  constant  than  that  which 
occurs  earlier.  The  early  coughing  is  usually  paroxysmal  some  minutes 
or  hours  elapsing  between  the  seizures.  These  intervals  may  be  entirely 
quiet,  but  are  often  attended  with  an  occasional  cough  which  interrupts 
the  sleep  of  exhaustion. 

Dyspnoea  is  a  very  frequent  symptom.  It  is  usually  inspiratory  in 
character,  but  may  be  expiratory  or  both.  It  may  be  due  to  actual  ob- 
struction to  the  passage  of  air  by  the  presence  of  the  foreign  substance 
itself,  or  by  the  bulk  of  the  body  plus  the  resultant  swelling  and  secre- 
tions ;  or  it  may  be  due  to  the  air  hunger  from  the  diminished  mucosal 
surface  reachable  by  air.  Tlie  dyspnoea  is  always  worse  during  the  par- 
oxysms of  coughing,  at  which  times  it  may  reach  unconsciousness  from 
carbonic  acid  narcosis. 

It  is  worth  while  bearing  in  nn'nd  that  dyspnoea  may  be  present  in  a 
case  where  the  foreign  body  is  in  the  esophagus,  but  is  eroding  through. 


86  DIAGNOSIS  OF  FORllIGN  BODY. 

as  in  a  case  of  the  author's,  elsewhere  reported  in  tliis  book,  or  by  dis- 
placement of  the  trachea  due  to  its  bulk. 

The  temperature  is  usually  elevated  which  is  often  misleading,  and 
in  cases  of  doubtful  diagnosis  will  be  erroneously  advanced  as  negative 
evidence,  and  urged  against  a  diagnosis  of  foreign  body.  It  may  be,  in 
the  earl)-  stages,  irritative.  Later  it  is  toxemic  due  to  septic  absorption 
from  a  localized  inflammatory  area.  It  may  be  due  to  the  complications 
as  pneumonia,  bronchitis,  etcetera. 

Chills  are  often  present.  They  are  due  to  the  same  causes  as  the 
elevation  of  temperature,  together  with  which,  especially  in  abscess  cases, 
they  may  closely  simulate  pulmonary  tuberculosis. 

Hciiioplysis  is  not  very  constantly  present,  but  when  it  occurs,  it  is  a 
valuable  symptom.  Blood  most  frequently  occurs  as  streaks  or  clots 
in  the  expectoration  :  only  in  case  of  very  sharp  bodies  is  it  in  any  amount, 
and  is  then  dependent  on  the  accident  of  cutting  a  small  vessel. 

Pain  is  often  noted  but  it  is  apt  to  be  vaguely  localized  and  may  be 
due  to  tissue  soreness  due  to  violent  coughing. 

Dl.-VGNOSIS. 

The  Roentgen  Ray.  In  all  cases  even  in  those  where  there  is  little 
hope  of  the  foreign  body  showing  opacity  to  the  ray,  a  radiograph  should 
be  taken  if  the  conditions  are  not  urgent.  If  there  is  very  urgent  dysp- 
noea, there  should  be  no  delay,  not  only  on  account  of  the  urgency,  but 
because  the  dyspnoea  itself  is  an  indication  that  the  foreign  body  is  in  the 
larvnx  or  trachea,  or  at  any  rate  not  lower  than  a  main  bronchus. 

The  fluoroscope  is  not  reliable  as,  unless  quite  dense,  the  corpus 
delicti  will  not  be  seen.  A  radiograph  should  be  made  in  all  instances 
and  should  be  interpreted  b\'  the  Roentgenologist,  as  few  others  see  a 
sufficient  number  of  radiographs,  normal  or  abnormal,  reliably  to  interpret 
the  plate.  Even  then  mistakes,  both  negatively  and  positively,  are  apt  to 
occur  occasionally. 

The  production  of  the  radiographic  shadow  by  a  foreign  body  is  a 
matter  of  the  density  of  the  foreign  substance. 

This  shciuld  be  remembered  when  deciding  whether  the  substance  of 
which  there  is  a  history  in  the  particular  case  would  show  radiographi- 
callv  or  not.  ^Metallic  substances  with  the  exception  of  aluminum  usually 
show  clearly.  Aluminum  will  only  show  when  of  some  little  bulk,  and  on 
a  radiograph,  not  upon  a  fluoroscopic  screen.  Pewter  and  lead  usually 
throw  dense  shadows.  Fig.  57  illustrates  how  clearly  a  cast  pewter  shirt 
button  in  the  trachea  was  demonstrated  radiographically,  in  an  infant 
referred  to  me  h\'  Dr.  Day.  The  child  was  turned  partly  sidewise  to  en- 
deavor to  prcyent  the  shadow  of  the  foreign  body  overla}'ing  that  of  the 


FOR  max  BODY. 


87 


Fl(..   ."id. — I5oiir   ill   hrunclms  of  iiiaidi'u   of  IS 


year.s. 


88 


FOREIGN  BODY. 


FiG-   oT. — Pewter  shirt  bulluu   in  the  trachea  of  au  iiifaul 


DIAGNOSIS  OF  FOREIGN  BODY. 


89 


vertebr.^-an  unnecessary  precaution  in  this  case  on  account  of  the  very 

dense  shadow  cast  by  the  alloy  of  lead. 

Inorganic  substances  other  than  metal,  such  as  pebbles,  toy  marbles, 

elass,  and  the  like,  usually  show  well. 

Or-anic  substances,  such  as  bones,  containing  considerable  quantities 

of  earthy  salts,  usually  show  well  if  not  overlying  the  bones  of  the  patient, 

especialiv  the  vertebrae.  _ 

The  particular  bone  in  question  has  nnich  tn  dn  with  the  decision. 
The  hard  dense  bones  .show  best,  the  semi-cartilaginous  bones  least,  bulk 
for  Inilk  If  it  is  a  question  of  fish  bone,  the  determination  of  whether  it 
is  a  vertebral  or  rib  bone  is  of  value.  Rib  bones  of  the  fish,  ca,st  almost 
no  shadow  and  even  the  vertebral  bones  as  a  rule  will  not  show  unless  of 
crood  size  and  not  overlving  the  patient's  denser  bones.  Fig.  56  is  from 
a  radiograph  which  shows  clearly  a  small  fragment  of  bone  in  a  secondary 
bronchus  Had  the  bone  been  less  dense,  or  had  its  position  overlaid  the 
vertebral  colunm  or  even  a  rib.  or  had  the  radiograph  been  poor  tins  bone 
would  not  have  shown,  and  the  author  would  not  have  had  permission  to 

remove  it.  . 

Vegetable  substances  as  a  rule  do  not  show  well,  unless  quite  dense, 

as  some  kinds  of  woody  fibre. 

Various  nut  kernels  within  the  thorax  are  not  easy  to  demonstrate 
radiographicallv.  Some  of  them  are  not  very  important  as  they  are  apt 
to  macerate  and  be  coughed  out.  This  is  more  especially  true  of  the 
cooked  kernels,  such  as  peanuts  and  chestnuts.  The  shells  or  hulls  of 
hard-shelled  nuts  usually  throw  radiographic  shadows. 

In  all  this  work,  it  is  important  to  have  the  very  best  possible  radio- 
graphic technic.  With  a  history  of  a  metallic  body,  and  in  an  unruly, 
terrified  child,  it  is  usual  to  make  too  short  an  exposure,  and  to  fail^  to 
hold  the  child  still.  Tliis  usually  suffices,  but  is  of  little  value  if  negative. 
In  rare  instances,  it  may.  as  pointed  out  by  ^losher  apropos  of  one  of  the 
author's  cases,  be  dangerously  deficient  in  not  showing  other  conditions 
such  as  a  hypertrophic  thymus  gland,  that  might  he  the  cause  of  the  symp- 
toms wrongly  attributed  to  the  supposed  foreign  body. 

In  few  cases  is  it  wise  to  decline  endoscopically  to  examine  a  patient 
because  the  radiograph  shows  nothing.  Only  in  the  case  of  a  metallic  or 
other  dense  substance  failing  to  show  upon  a  technically  good  radiograph 
should  we  reassure  ourselves  and  patient  that  nothing  is  present.  Even  in 
such  cases,  if  there  are  any  symptoms  to  corroborate  the  history,  it  is 
safer  to  tracheo-bronchoscopize,  and,  usually,  either  the  cause  of  the  symp- 
toms, be  it  foreign  body,  traumatism,  lesion  or  neurosis,  will  be  discov- 
ered ;  or  the  absence  of  such  cause  will  be  positively  demonstrated. 

An  otherwise  unexplainablc  dyspnoea,  especially  if  intermittent  and 


90  PHYSICAL  SIGNS  OF  FORHIGX  BODY. 

unassociatcd  with  fever,  is  almost  diagnostic  of  foreign  body  in  the  air 
passages. 

As  a  matter  of  fact,  however,  fever  is  nearly  always  present,  except 
in  the  early  stages.  So  much  so  that  with  the  chills,  cough,  and  expecto- 
ration, there  is  no  doubt  that  many  a  case  of  abscess  from  a  foreign  body 
has  gone  to  the  grave  labelled  erroneously  with  the  diagnosis  of  tubercu- 
losis. Usually  the  persistent  absence  of  bacilli  in  the  sputum  will  decide. 
But  it  must  not  be  forgotten  that  a  foreign  body  abscess  may  be  or  become 
tubercular.  The  author  has  seen  one  such  case.  In  addition  it  must  not 
be  forgotten  that  a  tuberculous  subject  may,  as  well  as  anyone,  inhale  a 
foreign  body.  Of  this  also  the  author  has  seen  one  case,  a  girl  of  i8  years 
who,  in  taking  a  deep  inspiration  after  a  sudden  coughing  paroxysm  at 
table,  aspirated  a  small  piece  of  beef  bone.  The  radiograph  was  doubt- 
ful (by  some  the  shadow  being  thought  to  be  the  shadow  of  a  vertebral 
process.  Fig.  56),  and  it  was  some  time  before  the  author  was  permited 
to  remove  the  bone  from  a  secondarv  bronchus. 

Physical  signs  are  of  value  diagnostically  if  done,  not  by  a  laryngolo- 
gist,  but  one  who  is  accustomed  to  auscultatory  and  percussive  work.  In 
other  words,  one  who  has  educated  his  ear.  Perhaps,  the  most  value  will 
attach  to  the  physical  signs  as  indicating  which  side  the  foreign  body  is  on, 
especially  in  a  case  of  a  negative  radiograph.  This  is  an  important  part 
of  the  diagnosis,  often  saving  time  by  indicating  which  side  to  search  first ; 
though  in  no  case  should  this  lessen  the  necessity  of  examining  the  other 
side  in  case  of  failure  to  find  the  corpus  delicti,  which  may  have  in  the 
meantime  been  coughed  up  and  re-aspirated  into  the  other  side. 

The  following  notes  prepared  at  the  request  of  the  author  by  Dr.  John 
\V.  Boyce,  will  be  found  exceedingly  valuable. 

The  physical  signs  are  as  a  rule  illy  reported  in  published  cases,  and  seem 
to  have  been  studied  with  but  scant  interest.  They  are  apparently  insufficient 
for  diagnosis.  Frequent  cases  of  serious  lung  trouble  are  explained  and  ter- 
minated by  the  coughing  up  of  an  unsuspected  foreign  body,  but  I  can  find 
no  instance  in  which  the  diagnosis  was  made  in  the  absence  of  history.  Yet 
the  findings  in  physical  examination  are  occasionally  quite  distinctive,  and 
very  frequently  of  use  in  localization.  It  is  to  be  hoped  that  wider  use  of  the 
X-raj'  and  of  modern  methods  of  exploration  will  not  overshadow  ausculta- 
tion whose  full  value  has  certainly  not  been  exploited  as  yet. 

In  the  examination  a  distinction  must  be  made  between  those  signs  due 
simply  to  the  presence  of  the  foreign  body  and  those  due  to  the  inflammatory 
accidents  which  rapidly  follow. 

In  the  classic  period  of  auscultation,  two  pathognomonic  signs  were  de- 
scribed; a  laryngeal  click  due  to  body  fixed  in  the  larynx,  "the  bruit  of  the 
standard"  (resembling  the  flapping  of  a  flag  in  the  wind)  caused  by  a  body 
loose  in  the  trachea.  It  has  not  been  my  fortune  to  observe  either  of  these 
nor  are  they  mentioned  in  recent  literature,  possibly  because  bodies  ui   these 


PHYSICAL  SIGXS  OP  POKPIGN  BODY.  5)1 

localities  .irc  so  easy  of  diagnosis  or  tlic  operative  indication  is  so  plain  and 
urgent  as  to  forestall  careful  examination. 

A  body  obstructing  the  bronchus  may  lead  to  atelectasis  of  the  lung  with 
the  ordinary  signs  of  this  condition.  This  occurrence  is  not  so  frequent,  how- 
ever, as  is  generally  supposed.  The  most  common  finding  is  a  marked  local 
diminution  of  the  respiratory  murmur  together  with  preservation  or  accentua- 
tion of  the  normal  resonance  and  this  may  be  rated  as  the  typical  condition 
in  foreign  body  cases.  When  a  body  partially  obstructs  the  bronchus  it  may 
give  rise  to  a  peculiar  dry  rale,  easily  distinguished  in  quality  from  tliat  of 
inflammatory  or  tubercular  thickenings  of  the  mucous  membrane.  Even  vv'ere 
this  distinctive  quality  lacking  it  is  scarcely  possible  for  inflammatory  condi- 
tions to  produce  dry  rales,  limited  always  to  a  particular  area  and  remaining 
unchanged  for  hours  at  a  time.  Such  a  condition  would  seem  to  justify  ex- 
ploration. The  case  of  Infant  J.,  which  I  have  reported,  furnished  an  example 
of  a  whistling  rale  heard  over  one  cone  of  lung  in  which  the  respiratory  mur- 
mur was  first  diminished  and  later  replaced  by  moist  rales  due  to  the  consecu- 
tive bronchitis. 

Of  consecutive  inflammatory  conditions,  the  most  common  and  earliest  is 
a  moist  localized  bronchitis.  Unfortunately  the  secretions  of  the  diseased  area 
are  apt  to  be  inspired  into  normal  bronchial  tubes  and  so  when  the  case  first 
comes  under  observation  we  may  find  the  signs  of  diffuse  bronchitis.  Even  so 
it  is  to  be  remembered  that  diffuse  bronchitis,  with  very  bloody  expectoration, 
coming  on  suddenly,  is  a  most  unusual  condition  and  would  produce  shock  or 
septic  phenomena  with  less  prominence  of  dysptioea  and  cyanosis.  Expectora- 
tion in  foreign  body  cases,  is  usually  bloody  and  has  a  great  tendency  to  be- 
come free,  purulent,  and  fetid.  The  diagnosis  usually  made  in  these  cases  is 
that  of  tuberculosis;  but  systematic  examination  of  the  sputum  should  guard 
against  error.  If  localized  abscess,  gangrene  or  pneumonia  of  lobular  type  re- 
sults, it  is  indistinguishable  by  physical  signs  from  similar  conditions  due  to 
the  more  ordinary  causes.  Lobar  pneumonia  sometimes  occurs.  One  most 
interesting  case,  reported  by  Ingals,  gave  a  typical  picture  of  pleural  effusion 
and  two  attempts  at  tapping  had  been  made  before  the  case  was  referred  for 
bronchoscophy. 

It  is  very  evidtnt  that  auscultation  for  localization  may  be  useful  as  a  pre- 
liminary to  bronchoscopy.  It  is  perhaps  too  much  to  hope  that  the  presence 
of  foreign  bodies  will  ever  be  diagnosticated  by  this  means  alone,  but  should 
often  lead  to  suspicion.  "Tuberculosis"  without  bacilli  in  the  sputum,  particu- 
larly if  located  towards  the  base  of  the  right  lung;  unilateral  or  unilobular 
bronchitis;  more  paiticularly  if  hemorrhagic  or  fetid  in  character;  atelectasis 
abscess  or  gangrene  not  otherwise  explainable — these  conditions  should  sug- 
gest the  possibility  of  the  presence  of  foreign  body  in  the  bronchi. 

The  most  likely  point  of  lodgment  of  a  foreign  body  depends  some- 
what upon  its  form  ,md  surface.  Smooth  round  bodies  usually  lodge  in 
the  smallest  bronchus  that  will  admit  them,  stopping  at  a  bifurcation  or, 
rather,  the  giving  ofl  if  a  lateral  branch.  Pins,  tacks,  and  nails  are  likely 
to  drop  head  downward  into  a  small  bronchus.  Safety  pins,  imless  closed, 
rarely  get  into  the  air  lassagcs. 

The  radiographic  localization  as  to  the  ])articular  air  passage  invaded 


92      TRACHEO-BRONCHOSCOPY  FOR  FOREIGN  BODIES. 

has  been  touched  upon  wlien  writing  of  the  anatomy  of  the  tracheo-bron- 
chial  tree. 

Tech  NIC. 

There  is  httle  to  add  to  what  has  been  said  previously  on  the  general 
subject  of  technic,  save  in  regard  to  the  use  of  the  forceps,  hooks,  et  cetera. 

The  chief  difficulties  other  than  those  previously  enumerated  arise  in 
the  case  of  very  small  bodies  very  deeply  located  in  small  bronchi^  es- 
pecially if  macerated  and  embedded  in  the  swollen  mucosa. 

In  working-  near  the  periphery,  with  unilluminated  tubes,  it  may  be- 
come impossible  to  work  by  sight,  as  the  forceps  shut  off  what  little  light 
enters.  The  forceps  have  to  be  passed  blindly,  reliance  being  placed  upon 
memory  of  the  previously  observed  position  of  the  foreign  body.  A  mark 
must  have  been  previously  placed  upon  the  forceps  canula  to  show  when 
the  point  of  the  forceps  has  reached  the  distal  end  of  the  tube.  The  sense 
of  touch  is  not  of  much  aid  even  in  case  of  metallic  foreign  bodies  for  con- 
tact of  the  forceps  with  the  tube  gives  a  confusing  sensation  of  metallic 
contact.  In  case  of  a  soft  foreign  body,  the  sensation  would  be  no  differ- 
ent from  touching  the  mucosa.  Ingals,  who  has  done  some  of  the  most 
brilliant  work,  always  inserts  and  uses  the  forceps  without  light. 

In  the  trachea  and  larger  bronchi  of  adults,  there  are  no  difficulties 
other  than  those  previously  mentioned.  The  use  of  forceps  through  the 
large  tubes  is  not  difficult,  especially  if  illuminated  tubes  are  used.  In 
children  under  3  years  of  age  the  small  tubes  used  render  the  procedure 
more  difficult,  though  the  shorter  length  of  tube  required  is  some  com- 
pensation. 

\'ariously  shaped  hooks  are  often  of  use  in  turning  over  foreign 
bodies  into  a  position  where  they  can  be  seized  with  the  forceps,  and  occa- 
sionally they  may  afford  sufficient  hold  entirely  to  remove  the  foreign  sub- 
stance. They  are  passed  flat  until  below  the  intruder,  then  rotated  so  as 
to  come  up  below  it,  when  they  are  withdrawn  until  they  come  in  contact 
with  it.  Fully  curved  hooks  must  be  used  cautiously  lest  they  get  caught 
in  a  bronchia!  orifice. 

In  case  of  hollow  foreign  bodies  the  expanding  forceps  (Fig.  21)  will 
be  found  of  service  if  it  can  be  inserted  into  the  hole  in  the  intruder,  which 
is  then  held  by  expansion  of  the  forceps  in  somewhat  the  same  manner  as 
is  an  intubation  tube  in  the  extubator.  It  is  not  intended  to  be  screwed 
into  the  foreign  substance  as  might  be  inferred  from  its  appearance.  It  is 
roughened  to  lessen  the  likelihood  of  its  slipping. 

Usually  outcoming  exudate  or  secretion  will  indicate  the  bionchus 
invaded;  or  if  the  foreign  body  has  been  in  for  sometime,  inflammatory 
signs  will  indicate.  In  one  of  the  author's  cases  the  orifice  was  swollen 
shut,  but  the  intruder  was  felt  beyond  with  the  probe  and  removed. 


FOREIGN  BODIES. 


!)3 


Fig.  58. — Foreign  bodies  from  the  air  passages. 
(From  the  author's  collection.) 

A,  Shirf  button  from  trachea  of  19  year-old  boy.     Cocain.     Upper  tracheoscopy. 
I,  IVbblc  from   left  bronchus  of  man  of  28  years  of  age.     Ether.     Upper  bron- 
choscopy 

B,  Penny,   which    in   2   nioi.ths   ulcei'ated   through    into    trachea    from    esophagus. 
2  year-old  child.     Chloroform. 

C,  Shoe  button  in  bronchus  2  years.  Maid  of  IS  years.  Upper  tracheoscopy. 
L),  Bono  from  bronchus,  maid  of  IS  years.  Upper  bronchoscopy.  Chloroform. 
G,   I'in  from  trachea  of  woman  aged  20.     Upper  tracheoscopy.     Chloroform. 

E,  Fragments  of  egg  shell   from   larynx.     Symptoms  simulated   croup ;   antitoxiu 
given.      Infant  0  months  old.     Direct  laryngoscopy.     No  anesthesia. 

H,  Fron    right  secondary   bronchus,   man   aged   24   years.     Upper  bronchoscopy. 
Chloroform. 

F,  From  trachea.     Boy  14  years  of  age.     Cocain. 


Part  11. 

ESOPHAGOSCOPY. 


CHAPTER    IX. 

Lsophagoscopy. 

Introduction. 

By  esophagoscopy  is  understood,  at  the  present  day,  the  examination 
of  the  esophagus  with  tlie  aid  of  tubes  introduced  through  the  mouth.  By 
retrograde  esophagoscopy  is  meant  the  examination  of  the  lower  end 
of  the  esophagus,  with  the  aid  of  tubes  introduced  upward  from  below 
through  a  celiotomic  wound. 

In  dealing  with  this  subject,  to  avoid  iteration,  the  difficulties,  dan- 
gers, contraindication  and  much  of  the  technic  will  be  deferred  for  subse- 
quent consideration  along  with  the  same  topics  under  "Gastroscopy." 

The  use  of  the  flexible  esophageal  bougie  has  no  place  in  this  book, 
and,  in  the  author's  opinion,  it  has  no  place  in  the  advanced  surgery  of 
the  esophagus.  In  remote  localities,  where  no  other  instnmient  is  avail- 
able, it  may,  as  a  makeshift,  yield  information  otherwise  unobtainable, 
and  may  serve  slightly  to  open  a  stricture,  but  its  use  is  attended  with 
great  risk,  because  the  end  is  beyond  control.  Instruments  passed  by 
sight  with  the  aid  of  the  esophagoscope  are  alone  permissable. 

It  is  not  possible  within  the  limits  of  this  manual  to  attempt  the  con- 
sideration of  diseases  of  the  esophagus.  Only  a  few  of  the  more  frequent 
conditions  will  be  considered,  and  these  but  briefly. 


CHAPTER    X. 
Anatomical  Notes  on  the  Esophagus. 

It  is  not  intended  to  go  into  the  anatomical  details,  but  there  are  a 
few  points  in  the  gross  anatomy  of  the  eso])hagus  that  must  be  borne  in 
mind  in  the  passage  of  rigid  straight  instruments  down  its  lumen. 

Dimi;nsions. 

Length.  The  wide  and  bewildering  differences  in  the  length  of  the 
esophagus  as  given  by  different  authorities  are  due  to : 

1.  Different  anatomical  points  from  and  to  which  measurements 
are  taken. 

2.  Observations  in  some  instances  upon  the  cadaver,  in  others  upon 
the  living,  yielding  differences  due  to: 

3.  The  elasticity  of  the  esophagus,  which  is  greater  in  the  living 
than  in  the  dead  subject,  and  which  permits  of  extension  and  displace- 
ment. 

4.  The  movements  and  displacements  of  the  esophagus. 

5.  Anatomical  variations  which  are,  with  few  exceptions,  wider 
than  in  any  other  organ  in  the  body.  Besides  anomalous  variations,  there 
are  those  more  or  less  regular,  corresponding  to  age,  sex,  height  and  body 
weight. 

To  go  at  length  into  tliese  variations  in  dimensions  would  be  out  of 
place  in  a  practical  manual.  The  practical  working  lengths  are  those 
taken  from  the  upper  teeth  as  a  starting  point.  The  following  table  com- 
piled from  Stark  by  iMosher  is  convenient: 


IjENGTH  OF  THE   ESOPHAGUS 

4T  Different  Ages. 

Teeth  to  Cricoid. 

To 
Bifurcation. 

To  Cardia. 

I^ength  of  Whole 
Esophagus. 

Birth,        7  cm.  (2^  in.) 

12  cm.  (  i%  in.) 

14  cm.  (  by,  in.) 

15  cm.  (6     in.) 

17  cm.  (   6'4  in.l 

18  cm.  (  7      in.) 
23  cm.  (  9     in.) 
26  cm.  (lOM'n.) 

18  cm.  (  634  in.) 

22  cm.  (  S'i  in.) 

23  cm.  (  9     in.) 
26  cm.  (10'4  in) 
28  cm.  (11      in.) 
33  cm.  (13      in.) 
40  cm.  (I.V4  in.) 

10  cm.  (4     in  ) 

12  cm    (  4^4  in  I 

2  years  10  cm    (4      in  ) 

13  cm    (  5^rt  in  ) 

10  years   10  cm    (4      in.) 

18  cm    (7      in  ) 

Adult.      l.'j  cm.  (6      in.) 

25  cm.  (10     in.) 

98 


ANATOMICAL  NOTES. 


The  diameter  of  the  esophageal  Uinien  is  subject  to  relativel}'  greater 
variations  than  its  length.  It  is  not  at  any  point  a  definite  dimension 
owing  to  the  elasticity  of  the  esophageal  wall.  For  practical  purposes, 
however,  it  is  only  necessary  to  consider  its  diameter  at  the  four  points  of 
constriction. 

Mosher's  compilation  from  Stark  is  practical. 

Diameters  of  the  Ksophagus  at  the  Four  Constrictions. 


Constriction, 

Diameter. 

Vertebra. 

Transverse  24  mm    (1  in  ) 

Diaphragm 

Transverse  23  mm.  {1  in.  +) 

Antero-posterior  23  mm    (1  in  — ) 

Tenth  thoracic 

For  esophagoscopic  purposes  the  most  important  constriction  is  at  the 
introitus.     This  has  already  been  described. 

The  next  constriction  in  point  of  importance  is  at  the  hiatus 
esophageus.  The  opening  in  the  diaphragm,  which  goes  by  this 
name,   (Fig.  59),  is  subject  to  wide  variations  dependent  upon  the  state 


Fig.  .59. — Under  surface  of  the  diaphragm. 
E,  Hiatus  e.sophageus.     Note  the  direction  of  its  axis. 
A,  Aortic  opening. 
VC,  Opening  for  vena  cava.     Note  direction  of  tendons  and  muscular  fibers. 

of  the  diaphragmatic  muscular  fibres,  whether  these  be  in  a  state  of  relax- 
ation, normal  contraction,  or  spastic  rigidity.  Tliese  are  important  points 
to  bear  in  mind.  The  axis  of  the  lumen  at  this  point,  (I"ig.  59)  should  be 
memorized,  as  it  is  exceedingly  useful  to  know  in  passing  the  esophago- 
scope  and  gastroscope. 


POSITION  OF  THE  ESOPHAGUS.  99 

Between  the  two  constrictions  just  mentioned  are  two  others  of  lesser 
importance.  They  are  often  not  noticed,  unless  watched  for  closely.  The 
upper  of  these  being  the  second  constriction  from  above  downwards,  cor- 
responds to  the  arch  of  the  aorta,  opposite  the  fourtii  thoracic  vertebra, 
back  of  the  manubrium  sterni.  This  is  often  exaggerated  in  esophago- 
scopy  by  the  active  pulsation  of  the  aorta,  due  to  excitement  or  to  mor- 
phin  or  ether  stimulation. 

The  other  constriction,  being  the  tliird  from  above  downward,  cor- 
responds to  the  crossing  of  the  left  bronchus  in  front  of  the  esophagus,  at 
the  level  of  the  fifth  thoracic  vertebra. 

All  of  these  constrictions  are  distensible,  the  upper  one,  at  the  introi- 
tus,  less  so  than  the  others.  The  extreme  elasticity  of  the  esophageal 
walls  penuits  of  stretching  the  normal  adult  esophagus  to  over  two  centi- 
meters without  rupture,  though  this  is  not  available  for  esophagoscopy. 
For  practical  purposes  it  is  onlv  necessary  to  remember  that  in  a  normal 
esophagus  the  following  sized  rigid  tubes  should  pass  freely: 

Infants 7  '■"'"• 

Adults TO  mm. 

Considerably  larger  tubes  may  be  used  in  many  cases,  but  in  all  cases 
where  these  cannot  be  passed,  stricture,  spasmodic  or  anatomic,  exists. 
Flexible  bougies  of  8  mm.  diameter,  should  pass  in  infants  and  children 
up  to  ten  years  of  age,  and  in  adults  14  mm.  should  pass.  Though  for 
reasons  given  elsewhere  the  author  disapproves  of  the  use  of  the  bougie 

Position.  Beginning  at  the  level  of  the  bifurcation  of  the  trachea, 
the  gullet  curves  around  the  aorta  decendens,  to  the  left  of  which  it  passes 
through  the  hiatus  close  to  the  vertebrae. 

The  subphrenic  portion  of  the  esophagus  which  deviates  to  the  left 
has  a  certain  range  of  mobility,  amounting  to,  apparently,  10  or  15  centi- 
meters in  relaxed  persons  of  spare  build.  It  is  apparently  attached  to  the 
surrounding  tissues  by  loose  cellular  tissues.  It  is  this  mobility  which 
renders  it  possible  to  introduce  a  straight  and  rigid  gastroscope  which 
straightens  out  the  cur\'e  and  the  deviation  of  this  subphrenic  portion  of 
the  esophagus. 

In  studying  the  gross  anatomy  of  the  esophagus,  the  first  essential 
point  to  remember  is  that  the  esophagus  is  never  twice  alike,  not  only  in 
dififerent  individuals,  but  in  the  same  individual  at  different  moments.  The 
only  really  fixed  point  is  at  its  junction  with  the  posterior  pharyngeal  wall. 
All  other  portions  are  subject  to  various  movements,  intrinsic  and  those 
imparted  by  contiguous  structures.  The  intrinsic  movements  are  those  of 
deglutition  and  its  reverse  regurgitation.  The  extrinsic  or  transmitted 
movements  are   respiratory  and   pulsatory.     The   respiratory   movements 


100  MOVEMENTS  OF  THE  ESOPHAGUS. 

are  noticed  chiefly  in  the  thoracic  esophagus,  and  consist  in  a  dilatation,  or 
opening  up.  of  the  esophageal  lumen  due  to  the  negative  intra-thoracic 
pressure. 

The  normal  pulsatory  movements  are  aortic  and  cardiac,  due  to  the 
pulsatile  pressure  of  the  aorta  at  the  level  of  the  fourth  thoracic  vertebra, 
(24  cm.  from  the  upper  teeth  in  the  adult),  and  of  the  heart  itself  noticed 
most  markedly  at  about  the  level  of  the  seventh  and  eighth  thoracic  ver- 
tebrae (about  30  cm.  from  the  upper  teeth  in  the  adult).  These  move- 
ments vary  greatly  within  the  limits  of  health. 

The  intrinsic  movements  of  the  esophagus  are  involuntary  muscular 
contractions,  as  in  deglutition,  and  regurgitation ;  and  spasmodic,  the  lat- 
ter usually  having  some  pathologic  relation. 

The  presence  of  a  sphincter  at  the  cardia  has  been  much  discussed. 
Anyone  who  has  carefull}-  observed  cardio-spasm  must  admit  that  it  indi- 
cates the  presence  of  the  two  layers  of  muscular  fibres  surrounding  the 
cardia  as  described  by  Hyrtl.  Yet  the  author  feels  inclined  to  the  belief 
that  the  prevention  of  regurgitation  of  food  up  the  esophagus  is  due  large- 
ly to  a  kinking  of  the  esophagus  upon  itself  at  the  hiatus  diaphragmatis 
increased  by  expansion  of  the  stomach  when  dilated  with  food.  Whether 
this  be  true  or  not  remains  to  be  proven.  But  in  examinations  the  author 
has  frequently  noticed  this  kinking,  even  when  the  stomach  was  empty. 


tract. 


CHAPTER    XI. 

Normal  Lsophagoscopic  Appearances. 

The  form  of  the  esophageal  picture  changes  hi  various  portions  of  the 


The  introitus  esophagi  is  closed  by  the  constriction  produced  mainly 
by  the  inferior  constrictor  of  the  pharynx,  producing  a  backward  pressure 
of  the  cricoid  cartilage,  which,  at  all  times  except  during  the  act  of  swal- 
lowing, lies  in  contact  with  the  posterior  pharyngeal  wall. 

The  form  of  the  cervical  portion  of  the  esophagus  is  a  transverse  slit 
due  to  the  collapse  of  the  walls  from  before  backward,  it  opens  up  ahead 
of  the  tube  in  a  way  that  shows  a  more  or  less  flat  anterior  and  posterior 
wall,  meeting  at  the  sides.  Tliis  opens  and  closes,  often  audibly,  with  the 
respiratory  movements.  Upon  entering  the  thoracic  esophagus,  the  esoph- 
agoscope  reveals  a  more  or  less  oval  or  quadrangular  opening  into  the 
depths  of  which  the  observer  looks.  (Fig.  2.  Plate  III,  and  Fig.  i.  Plate 
IV.)  This  opening  is  very  much  smaller  than  the  entire  esophageal  lu- 
men, and  it  increases  very  much  with  each  inspiration,  lessening  but  not 
completely  closing  with  expiration.  The  position  of  this  opening  changes 
as  the  esophagoscope,  during  insertion,  is  deviated  to  one  side  or  the  other, 
and  in  case  of  great  deviation  it  may  disappear  altogether,  the  flat  wall 
only  being  in  view. 

At  the  hiatus  diaphragmatis  the  form  of  the  lumen  again  becomes  a 
slit,  the  axis  being  placed  obliquely  from  the  right  posterioriy  to  the  left 
anterioriy.      (See  Fig.  3,  Pate  III,  and  also  Fig.  59  in  the  text.) 

The  subphrenic  portion  of  the  esophagus  is  usually  opened  but  slight- 
ly by  respiratory  movements,  and  is  at  times  collapsed  by  movements  of 
the  diaphragm  and  the  abdominal  viscera.  The  observer  is  prone  to  con- 
sider it  collapsed  when  really  the  fault  is  in  the  gastroscope  not  following 
the  axis  of  the  esophageal  lumen. 

Folds  probably  do  not  exist  in  the  quiescent  state  of  the  esophagus. 
When  muscular  contractions  occur,  folds  probably  exist.  Of  these  thmgs 
there  is  no  absolute  certainty.     When  a  tube  is  introduced,  however,  the 


102  NORMAL  ESOPHAGOSCOPIC  APPEARANCES. 

wall  may  be  thrown  into  folds,  either  transverse  or  longitudinal.  There 
has  been  much  useless  discussion  upon  this  point,  one  observer  seeing 
one  kind  of  folds  and  another  observer  another  kind.  In  most  instances, 
in  the  author's  opinion,  the  folds  were  produced  by  the  manipulation  of 
the  esophagoscope. 

The  color  of  the  normal  esophageal  lumen  varies  greatly  in  different 
individuals,  in  the  same  person  at  different  times,  and  still  more  greatly 
does  the  apparent  color  vary  with  the  form  of  illumination.  With  the 
bright  white  light  of  the  self-illuminated  tubes,  the  mucosa  is  almost 
white,  shading  to  pale  grayish  pink.  With  reflected  sunlight  which  the 
author  used  experimentally  to  determine  the  color,  the  mucosa  seemed  to 
be  of  about  the  same  tint.  With  the  unilluminated  tubes  the  color  varies 
with  the  amount  of  light  that  reaches  the  mucosa.  If  well  illuminated, 
the  color  is  the  same  as  with  the  illuminated  tubes.  If  poorly  lighted  up, 
the  mucosa  seems  dark  red  or  brown.  The  colors  as  given  here  refer  to 
the  perfectly  cleansed  mucosa.  Overlying  secretions  vary  the  tint  greatly  ; 
so  also  may  drugs,  as  chloroform,  ether,  cocain,  etc.  The  surface  of  the 
mucosa  is  moist  and  glistening.  In  the  cervical  and  the  abdominal  por- 
tions minute  vascular  twigs  are  at  times  seen.  They  are  less  often  noted 
in  the  thoracic  portion  in  health.  A  fair  idea  of  the  appearance  of  the 
normal  esophageal  mucosa  may  be  conveyed  by  comparing  it  to  the  mu- 
cosa of  the  inside  of  the  cheek. 


CHAPTER    XII. 
Technic  of  Lsophagoscopy. 

Examination  of  the  Upper  End  of  the  Esophagus. 

The  examination  of  the  upper  end  of  the  esophagus  is  a  very  easy 
matter.  Technically  it  is  the  same  as  direct  laryngoscopy,  (q.  v.)  but  it 
is  much  easier  of  accomplishment  by  the  inexperienced.  It  may,  and 
should,  be  a  routine  procedure  in  the  consulting  room.  A  full  operating 
room  detail  is  not  necessary.  The  patient  is  told  to  arrive  with  an  empty 
stomach  and  a  clean  mouth.  The  positions  of  patient,  assistant  and  nurse 
and  apparatus  are  exactly  the  same  as  described  for  direct  laryngoscopy. 

The  pharynx  and  introitus  esophagi  are  cocainized  with  the  aid  of  a 
Sajous,  curved,  laryngeal  sponge  forceps.  The  tubular  speculum  is  then 
passed  down  back  of  the  tongue  until  the  epiglottis  comes  into  view.  It 
is  wise,  usually,  at  this  point  to  take  a  straight  applicator  dripping  with  a 
ID  per  cent  cocain  solution  and  cocainize  the  epiglottis  and  then,  passing 
on,  to  cocainize  the  laryngeal  orifice  and  tlie  introitus  esophageus,  waiting 
a  few  minutes  for  anesthesia  to  supervene. 

Tlae  tubular  speculum  is  passed  down  back  of  the  epiglottis  which  is 
lifted  forward  against  the  base  of  the  tongue.  This  brings  into  view  the 
arytenoids  which  are  seen  to  lie  in  contact  with  the  posterior  pharyngeal 
wall.  (Fig.  I,  Plate  III,  shows  this  as  seen  in  the  dorsally  decumbent 
patient.  To  get  the  view  as  seen  in  the  erect  patient,  invert  the  plate.) 
There  is  no  slit;  only  a  depression  is  seen.  The  spatular  end  of  the  tubu- 
lar speculum  is  inserted  in  this  slit,  far  enough  to  reach  below  the  aryte- 
noids and  engage  posteriorly  to  the  cricoid  cartilage,  which  is  lifted  for- 
ward, thus  exposing  the  pyriform  fossje.  (Fig.  60.)  The  lifting  forward 
of  the  cricoid  cartilage  exposes  the  upper  esophageal  lumen  as  seen  in  Fig. 
6,  Plate  III. 

Passing  the  Esophagoscope. 

Preliminary  to  the  passing  of  the  esophagoscope  for  any  cause  what- 
soever, the  tubular  speculum  should  be  used  ;  not  as  a  guide  through  which 


104 


TECHNIC  OF  ESOPHAGOSCOPY. 


to  pass  the  longer  tube,  as  in  tracheo-bronchoscopy,  but  to  gain  a  knowl- 
edge of  the  conditions,  nomial  or  pathologic,  of  the  upper  end  of  the  esoph- 
agus. This  will  prevent  the  danger  of  pushing  the  longer  tube  into  a 
lesion,  or  prevent  the  unnecessary  deeper  search  for  a  highly  located  for- 
eign body.  Furthermore,  examinations  should  be  thorough  and  thor- 
oughness is  only  accomplished  by  a  routine  examination  of  all  the  struct- 
ures seriatim   from  above   downward.     Thus,  not   only  is  all  chance  of 


Fic.  00. — Basr  of  llie  tongue  anil  iipijci-  border  of  the  uoruiiil  larynx,  viewed  from 
behind.  1.  Median  gIo?so-epiglottic  fold.  2.  Right  glosso-epiglottic  fossa.  .3,  Lateral 
glosso-epiglottic  fold.  4.  I'haryugo-cpiglottic  fold.  5.  Aryepiglottic  fold.  6,  Right 
pyriforni  sinus,  by  way  o£  which  esophagoscope  should  lie  passed. 

missing  anything  avoided,  but  we  reduce  the  dangers  of  esophagoscopy 
almost  to  naught,  bv  seeing  and  avoiding  penetration  or  even  abrasion  of 
all  weak  places  in  the  esophageal  wall. 

The  manipulations  of  passing  the  esophagoscope  arc  exactly  the  same 
as  those  of  passing  the  gastroscope  and  to  save  repetition  they  will  be 
given  in  the  cha]5ter  devoted  to  that  subject. 


CHAPTER    XIII. 
Diseases  and  Anomalies  of  the  Lsophagus. 

Anomalies. 

A'arious  congenital  anomalies  of  the  esophagus  occur,  but  their  ex- 
tended consideration  would  be  out  of  place  here.  The  esophagus  may  be 
bifid,  or  the  esophagus  may  end  in  a  blind  imperforate  pouch.  In  either 
case  the  child  seldom  lives  any  length  of  time.  Esophago-tracheal  fistula 
is  a  form  that  occurs,  and  some  such  cases  have  been  known  to  live.  In 
one  such  case,  a  valve-like  fold  of  mucosa  seemed  to  close  the  fistula  so 
that  no  food  escaped  into  the  trachea. 

Diseases  of  the  Esophagus. 

Diseases  of  the  esophagus  may  be  divided  into  stenotic  and  non- 
stenotic  classes.  Stenotic  diseases  may  be  classified  into  acute  inflamma- 
tory, neoplastic,  sjjastic  and  compression  .stenoses. 

The  non-stenotic  diseases  include  diverticula,  dilTuse  dilations, 
paralyses  and  pareses,  and  inflammations  and  ulcerations. 

In  all  of  these  diseases  the  esophagoscope  stands  ready  to  lend  inval- 
uable aid  for  the  purposes  uf  diagnosis  and  treatment.  But,  separately  to 
consider  all  these  diseases  would  far  exceed  the  scope  of  this  manual. 
Only  a  few  of  the  many  subjects  in  this  interesting  field  will  be  considered 
and  onlv  briefly. 


CHAPTER     XIV. 
Stenotic  Diseases  of  the  Lsophagus. 

Acute  Inflammatory  Stenoses. 

Acute  inflammatory  stenoses  must  be  approached  with  great  caution. 
As  a  rule,  when  they  are  due  to  a  corrosive,  as  lye,  or  carbolic  acid,  it  is 
better  not  to  pass  an  esophagoscope,  but  to  wait  for  the  inflammatory  re- 
action to  subside.  So,  too,  in  traumatic  cases,  when  the  implement  of 
traumatism  has  been  removed,  it  is  better  not  to  intrude  any  instrument. 
Better  results  will  be  obtained  by  waiting  a  week  or  more  for  the  acute 
inflammation  to  subside.  An  esophagoscopic  examination  then  will  en- 
able the  determination  of  a  plan  of  treatment  to  prevent  the  formation  of  a 
cicatricial  stenosis.  If,  however,  when  first  seen,  the  foreign  body,  mis- 
sile, or  implement  of  traumatism  is  still  present,  immediate  esophagoscopy 
is  imperatively  demanded.  After  removal  the  trauma  is  best  let  alone  for 
a  few  days  until  the  granulation  tissue  has  made  esophagoscopy  safe  and 
associated  remedial  measures  effective. 

Cicatricial  Stenoses. 

Cicatricial  stenoses  are  commonly  due  to  post-operative,  traumatic, 
escharotic,  luetic,  or  ulcerative  scars. 

The  diagnosis  of  the  presence  of  the  stricture  is  readily  made  esoph- 
agoscopically,  though  the  history  must  be  relied  upon  to  determine  the 
etiology. 

Post-operative  cicatricial  stenoses  are  usually  in  the  cervical  portion, 
as  intrathoracic  surgery  of  the  esophagus  is  as  yet  rarely  attempted.  The 
author  has  seen  a  number  of  cases  of  post -operative  esophageal  stenosis  of 
the  cervical  esophagus  follow  total  laryngectomy.  It  has  been  known  to 
follow  thyrotomy  for  malignant  disease,  though  it  would  seem  that  the 
proper  limits  of  thyrotomy  had  been  exceeded  in  such  cases.  In  excision 
of  malignant  disease  of  the  glands  of  the  neck,  the  esophagus  has  been 
resected  for  involvement,  with  resultant  stricture. 


STENOSES  OF  THE  ESOPHAGUS.  107 

Of  traumatic  stenoses,  the  most  frequent  forms  result  from  penetrat- 
ing gunshot  wounds,  and  from  swallowing  sharp  foreign  bodies,  as  glass, 
knives,  dentures,  etc. 

Escharotic  cicatricial  stenoses  are  perhaps  the  most  frequent.  In  the 
days  of  home  made  soap,  swallowing  of  caustic  soda  and  potash  in  the 
form  of  lye  was  not  an  infrequent  accident  to  children. 

Syphilitic  ulceration  of  the  esophagus  is  much  more  frequent  than 
generally  supposed,  and  the  author  has  seen  a  number  of  cicatricial  sten- 
oses from  this  cause. 

Of  the  ulcerations,  other  than  luetic,  that  may  be  followed  by  cicatri- 
cial contraction,  those  of  typhoid  fever  may  be  cited.  One  such  case  was 
seen  by  the  writer,  though  it  occurred  in  a  case  with  an  escharotic  history. 

Mr.  H.,  aged  l8  years,  was  referred  to  me  by  Dr.  A.  M.  Stevenson  for  a 
diagnosis  of  the  esophageal  condition.  During  the  fourth  week  of  typhoid 
fever  it  was  found  that  there  was  increasing  difficulty  in  swallowing  the  liquid 
food.  Finally  a  stage  was  reached  where  nothing  but  ice  cream  would  pass 
down,  and  fully  two-thirds  of  it  were  regurgitated.  Upon  passing  the  esopha- 
goscope,  an  old  hard  cicatrical  stenosis  was  found.  Upon  its  edge  there  was 
an  ulcer  of  linear  form,  long  a.xis  longitudinal.  The  old  cicatrices  (Fig.  4, 
Plate  III.)  were  also  longitudinal  giving  a  radiating  arrangement,  when  viewed 
through  the  esophagoscope.  Applications  of  argentic  nitrate  were  made  at  in- 
tervals and  resulted  in  a  complete  cure  of  the  ulcer,  though  the  difficulty  in 
swallowing  persisted  for  a  long  time,  eventually,  however,  recovering.  Upon 
close  questioning,  Dr.  Stevenson  elicited  a  vague  history  of  swallowing  lye  in 
childhood,  followed  by  some  swallowing  difficulty  which  soon  disappeared. 
For  14  years  there  had  been  no  trouble  in  swallowing  any  and  every  kind  of 
solid  or  liquid  food,  until  the  attack  of  typhoid  fever. 

The  treatment  of  cicatricial  stenosis  with  the  aid  of  the  esophagoscope 
has  yielded  very  satisfactory  results  in  many  cases  of  a  class  formerly  con- 
demned to  gastrostomy.  The  passing  of  bougies  blindly,  which  formerly 
was  the  chief  method  of  treatment,  is  now  only  used  for  the  maintenance 
of  a  dilation  accomplished  esophagoscopically.  Bouginage  was  a  danger- 
ous procedure  in  the  absence  of  any  definite  information  as  to  the  endo- 
esophageal  conditions  present  in  a  given  case.  In  the  absence  of  an  esoph- 
agoscopic  examination,  when  a  bougie  is  blindly  introduced  and  meets 
with  an  obstruction,  there  is  no  means  of  knowing  whether  it  has  encoun- 
tered a  stricture  or  the  bottom  of  a  diverticulum.  Obviously,  to  force  the 
bougie  under  such  circumstances  is  to  court  disaster.  Cases  of  stricture 
requiring  treatment  are  always  severe  cases,  so  that  they  require  a  very 
small  bougie.  Strictures  are  rarely  concentric  with  a  funnel  shaped  up- 
per portion  which  might  guide  the  bougie  to  the  stricture.  On  the  con- 
trary, there  are  folds,  bands,  pockets,  and  diverticula  that  render  the 
chances  very  much  against  a  bougie  finding  the  lumen  of  the  strictured 


108  BOUGINAGE  PER  TUB  AM. 

passage.  It  is  utterly  unjustifiable  under  these  circumstances  to  force  a 
small  bougie.  There  are  many  cases  of  death  from  this  unsurgical,  blind, 
rarely  justifiable  procedure.  Anyone  who  has  done,  or  seen  done,  the  pre- 
cise operation  of  passing  an  esophagoscope,  locating  the  stricture,  insert- 
ing an  instrument  therein,  dilating  the  stricture  and  restoring  the  patient's 
power  of  swallowing  will  never  endorse  the  reckless  making  of  false  pas- 
sages in  the  mediastinum,  pleura,  pericardium,  bronchi  or  lungs,  by  blind 
stabbing  with  a  bougie. 

If  the  stricture  case  gives  a  history  of  great  difficulty  in  getting  down 
soft  solids,  even  though  fluids  pass  without  difficulty,  it  will  be  found,  upon 
esophagoscopy.  that  the  lumen  of  the  stricture  is  exceedingly  small  and 
difficult  to  find.  One  wonders  how  even  fluids  could  leak  through  in 
sufficient  quantity  to  sustain  life.  In  such  cases  the  most  brilliant  results 
can  be  safely  obtained  with  the  aid  of  the  esophagoscope. 

The  best  form  of  bougie  for  these  cases  is  Bunt's  (Fig.  6i).  They 
are  made  with  two  olivary  bulbs ;  one  covering  the  point  and  one  a  size 
(French  scale)  larger,  situated  3  cm.  from  the  end.  Tliis  has  two  ad- 
vantages : 

I.  It  permits  following  up  a  sized  olive  that  passes  readily  and  safe- 
ly with  one  of  a  size  that  may  safely  do  some  dilating. 


Fig.  61. — Biiut's  (loul)le  olive  bougie. 

2.  The  distance  between  the  olives  permits  the  passage  of  the  inter- 
vening 3  cm.  of  stem  before  the  second  bulb  engages  in  the  stricture.  This 
acts  as  a  guide  and  assures  safety  in  using  some  force  on  the  second  bulb. 

Bunt  used  these  bougies  with  the  aid  of  the  sense  of  touch,  without 
the  esophagoscope,  and  obtained  excellent  results.  They  are,  however, 
more  accurately  and  advantageously  used  with  the  aid  of  the  esophago- 
scope. 

The  esophagoscope  is  passed,  the  esophageal  wall  closely  inspected, 
scars,  diverticula  and  other  abnormalities  examined.  When  the  tube 
mouth  reaches  the  constriction  that  is  loo  narrow  to  admit  it,  if  not  too 
small,  a  smaller  tube  may  be  passed  through  the  first,  or,  better,  the  first 
may  be  withdrawn  and  a  smaller  one  introduced.  In  many  cases  it  will 
be  found  that  this  first  stricture  is  but  the  vestibule  to  a  second,  smaller 
stricture.  Tiiere  may  be  several  strictures  and  in  one  instance,  the  author 
saw  six.  As  a  rule,  they  do  not  all  require  treatment  other  than  to  ensure 
their  getting  no  smaller.  Having  arrived  at  a  stricture  which  will  not 
permit  a  7  mm.   esophagoscope   to   pass,   the   esophageal   wall   ahead    is 


STENOSES  OF  THE  ESOFII.ICUS.  109 

sponged  clean  and  a  search  is  made  for  the  lumen  nf  the  '>tricturc.  Very 
often  this  will  be  of  almost  a  pin-hole  size  seen  in  tlie  ll:it  wall  against 
which  the  tube  moutl!  is  gently  pressed.  Often  prolonged  exploration  of 
a  diverticulum  or  a  number  of  diverticula  will  he  necessary  before  the 
strictural  opening  is  discoveretl.  When  found,  the  smallest  Hmit  bougie 
is  inserted.  If  it  pass  readil}',  the  next  size  is  inserted,  and  so  on  up  until 
a  size  is  reached  whose  distal  olive  passes  readily,  but  the  second  olive  en- 
gages. Tliis  is  pushed  through  and  the  next  larger  size  is  used.  At  the 
next  treatment,  three  or  four  days  later,  these  same  sizes  are  used  again, 
followed  bv  one  size  larger.  This  is  continued  until  a  sufficientl)'  large 
lumen  is  secured  to  permit  the  patient  to  swallow  solids  normally. 

The  ordinar\-  flexible  silk-and-wax  bougie  is  then  gently  tried  with- 
out the  esophagoscope,  the  patient  being  instructed  to  make  continual-swal- 
lowing efforts  wdiile  the  bougie  is  being  passed.  If  the  flexible  bougie 
pass  readily,  the  patient  is  taught  to  pass  it  himself,  and  instructed  to  pass 
it  regularlv  once  a  week  or  oftener,  if  any  signs  of  strictural  closure  super- 
vene. After  a  time,  once  a  month  will  be  enough.  This  may  be  called  a 
symptomatic  cure  and  is  brilliant  compared  to  gastrostomy,  either  with  or 
without  retrograde  chlatation. 

Of  the  other  methods,  dilatation  with  a  laminaria  tent  placed  with  the 
aid  of  the  esophagoscope,  deserves  mention.  It  is  carried  on  the  end  of  a 
stylet  fitted  to  the  tube  forceps  (Fig.  22).  The  disadvantage  to  tent  dila- 
tations is  that  the  tent  expands  more  below  the  stricture  than  at  it.  This 
lower  expansion  in  extraction  has  tc  be  pulled  through  th.e  stricture.  This 
is  not  often  difficult  to  do,  but  may  be  attended  with  slight  risk,  though 
no  cases  of  untoward  results  have  come  to  the  author's  knowledge.  The 
axial  tugging  on  the  esophagus,  rather  than  the  stretching  of  the  circum- 
ference constitutes  the  danger ;  for  as  demonstrated  sphygmomanometri- 
cally  by  Boyce  on  some  of  the  author's  cases  of  laryngectomy,  tugging  on 
the  esophagus  produces  a  great  fall  in  blood  pressure. 

Instrumental  dilatation  with  steel  expanding  forceps  is  a  feasible  pro- 
cedure and  is  advisable  in  a  few  instances.  There  is  always  some  risk  of 
rupture  of  the  esophageal  wall,  which  is  a  very  serious  complication. 
There  are  many  other  plans  of  treatment,  instrumental,  electrolvtic,  etc., 
but  that  given  is  the  most  practical. 

Medicinal  treatment  is  of  no  use  so  far  as  cure  is  concerned,  but  it 
may  be  well  to  know  that  cocain.  adrenalin  and  morphin  have  a  decided 
effect  in  temporarily  opening  a  stricture  sufficiently  to  permit  liquids  to 
pass.  This  is  of  use  at  times  in  tiding  over  a  few  davs,  when  the  patient 
is  not  seen  until  he  is  in  a  serious  state  of  inanition.  Under  these  circum- 
stances it  is  also  well  to  know  that  ice  cream  will  go  down  when  nothing 
else  will.     The  action  of  the  cold  probably  is  to  contract  the  chronically 


110  MALIGNANT  DISEASE  OF  THE  ESOPHAGUS. 

inflamed  mucosa,  so  as  temporarily  to  increase  the  available  lumen.  Of 
course  most  of  the  ice  cream  is  regurgitated,  but  enough  leaks  through  to 
prevent  starvation. 

Malignant  Disease  of  the  Esophagus. 

As  in  malignant  disease  elsewhere  in  the  body,  the  crime  of  the  day 
is  in  the  failure  to  recognize  malignancy  and  pre-malignant  conditions 
early.  It  is  not  until  emaciation,  cachexia,  regurgitation  and  absolute  ina- 
bility to  swallow  solids  supervene  that  the  profession,  even  the  laryngolog- 
ical  member  of  the  profession,  thinks  of  serious  disease  of  the  esophagus. 
All  earlier  stages  are  dismissed  thoughtlessly  with  the  label  "globus  hys- 
tericus."    Illustrative  of  this  the  following  case  may  be  cited : 

Miss  L.,  aged  41,  was  under  the  author's  care  for  chronic  maxillary 
sinuitis.  She  mentioned  incidentally  that  she  felt  a  lump  in  her  throat  at  times 
upon  swallowing.  When  asked  if  she  felt  the  lump  rise  in  her  throat  when  she 
was  not  attempting  to  swallow,  she  answered  that  at  times  she  did.  There  had 
been  no  difficulty  in  getting  even  solid  food  down,  and  there  was  no  regurgi- 
tation. She  was  undoubtly  a  neurasthenic,  yet  the  author  has  made  it  a  rule 
to  consider  that  a  neurasthenic  may  have  a  lesion  as  well  as  a  person  without 
neuropathy,  and  that  a  person  with  abnormal  esophageal  sensations  should  be 
examined  as  well  as  one  with  abnormal  laryngeal  sensations.  In  this  instance, 
it  was  two  months  before  the  attending  physician  grudingly  gave  his  consent 
to  an  esophageal  examination.  Under  ether,  preliminary  to  a  secondary  sinus 
operation,  the  esophagoscope  was  passed  and  an  epithelioma  (Fig.  8,  Plate 
III.)   discovered. 

The  foregoing  case  dlustrates : 

1.  The  latency  of  esophageal  symptoms. 

2.  TTie  necessity  for  the  examination  of  the  esophagus  in  all  cases 
where  any  chronic  throat  symptoms,  other  than  laryngeal,  are  complained 

3.  The  fallacy  of  labelling  (it  would  not  be  accurate  to  say  diagnos- 
ticating) a  case  of  "globus  hystericus,"  because  the  patient  complains  of 
"a  lump  rising  in  the  throat,"  whether  she  be  a  neurasthenic  or  a  hysteric 
subject  or  not. 

Malignant  diseases  of  the  esophagus  for  esophagoscopic  purposes 
may  be  divided  into  endo-esophageal,  muro-esophageal  and  peri-esopha- 
geal  diseases.  Naturally  this  only  applies  to  the  early  stages.  Late  in  the 
disease  all  three  forms  are  usually  combined. 

Peri-esophageal  disease  in  its  earlier  stages  will  present  a  hard  resist- 
ing sensation  to  the  end  of  the  esophagoscope,  though  the  overlying  muco- 
sa is  normal.  This  is  well  shown  in  Fig.  7,  Plate  III,  where  the  mass  is  to 
the  left,  the  lumen  to  the  right.  This  deviation  of  the  lumen  must  be  dis- 
tinguished from  the  simple  neglect  of  making  the  tube  follow  the  direction 


MALIGNANT  DISEASE  OF  THE  ESOPHAGUS.  1 1 1 

of  the  axis  of  the  normal  hinien.  The  figure  is  drawn  from  a  case  of 
epithelioma  in  a  man  6o  years  of  age,  referred  lo  me  by  Dr.  Sanes.  Tlie 
esophagoscope  could  not  be  introduced  past  the  hard  mass,  though  the 
mucosa  was  normal.  Later  the  wall  and  still  later  the  mucosa,  became 
involved. 

The  esophagoscopic  appearances  of  nuiroand  endo-esophageal  ma- 
lignancy varies  in  different  cases  and  in  different  stages.  In  the  early 
stage  Von  Acker  regards  distinctive,  slight  narrowing  of  the  lumen  with 
islands  of  infiltration  raising  the  mucosa  in  spots,  the  mucosa  being  red- 
dish with  purplish  hemorrhagic  dots,  and  with  here  and  there  enlarged 
vessels  visible.     This  is  an  early  condition  prior  to  ulceration. 

Gottstein,  whose  experience  is  large,  describes  five  forms  of  esoph- 
agoscopic appearances  in  esophageal  cancer. 

1.  Segmentary  mural  infiltration  in  thickened  whitish  patches  alter- 
nating with  bright  red. 

2.  Annular  form,  seen  as  a  more  or  less  extended  ring  of  infiltration 
which  narrows  the  lumen  below  a  fungating  ulceration  occupying  m.ore  or 
less  of  the  ring.  Above  this  ulcerated  area  there  is  more  or  less  dilatation 
dependent  upon  the  duration  of  the  narrowing.  The  mucosa  of  this  dilated 
area  is  more  or  less  altered. 

3.  Carcinomatous  infiltration  not  only  annular  but  funnel-shaped. 

4.  Bleeding  cauliflower  fungating  masses. 

5.  Papillomatous  vegetations. 

The  most  common  in  form  is  the  second. 

Stoerk  urges  the  diagnostic  importance  of  the  absence  of  the  respira- 
tory enlargement  and  the  diminution  of  the  esophageal  lumen,  due  to  infil- 
tration of  the  esophageal  walls.  He  also  attaches  weight  to  flat  infiltra- 
tion, bleeding  after  wiping,  and  superficial  ulceration  of  the  tumor. 

It  must  not  be  forgotten  that  all  of  these  appearances  may  be  simu- 
lated by  syphilis,  but  the  therapeutic  test  will  soon  distinguish. 

The  taking  of  a  specimen  is  in  all  cases  advisable,  and  is  quite  harm- 
less. If  bleeding  follow,  which  is  rare,  it  can  be  stopped  by  swallowing 
ice  cream,  iced  water,  or  pieces  of  ice.  Epithelioma  and  endothelioma 
may  be  distinguished  microscopically  with  some  degree  of  certainty,  if  an 
adequate  specimen  be  removed.  But,  obviously,  the  pathologist  can  only 
report  on  the  specimen  submitted,  so  that  a  good,  ample  specimen  must 
be  obtained,  preferably  one  at  the  edge  of  the  neoplasm  and  including  both 
normal  and  neoplastic  tissue.  In  cases  of  deep-seated  growth  covered 
with  normal  mucosa,  it  is  useless  to  take  a  specimen  unless  the  forceps  be 
plunged  deeply  into  the  mass,  which  is  seldom  justifiable.  In  fibro-sar- 
comata,  of  which  the  author  has  seen  one  case,  the  microscopic  appear- 
ances are  characteristic,  as  they  are  also  in  sarcomata  of  other  than  the 


112  BEXIGN  NEOPLASMS  OF  THE  ESOPHAGUS. 

small  round-celled  variety.  The  latter  form  is  not  with  certainty  dis- 
tino-uishable  from  tuberculoma,  syphiloma,  and  inflammatory  round-celled 
infiltration ;  at  least  such  has  been  the  author's  experience  from  small  in- 
adequate specimens  submitted  to  various  pathologists.  If  the  entire  mass 
or  a  portion  extending  from  the  surface  of  the  growth  clear  down  into 
healthv  tissue  be  obtained,  the  pathologist  would  have  a  fair  opportunity 
and  could  give  a  dependable  opinion  in  all  cases. 

Tlie  treatment  of  malignant  disease  of  the  upper  portion  of  the  esoph- 
agus when  associated  with  similar  disease  in  the  larynx  may  be  extirpated 
by  resection  of  the  esophagus  at  the  laryngectomy.  For  extensive  opera- 
tive work  upon  the  upper  end  of  the  esophagus,  Mosher's  ingenious  spec- 
ulum (Fig.  5)  is  well  adapted.  If  the  patient  be  not  tracheotomized  it  is 
necessary  to  watch  the  breathing  carefully  while  using  this,  as  the  broad 
flat  surface  is  apt  to  close  the  laryngeal  orifice.  The  author  has  had  a 
large  oval  opening  made  in  the  spatular  part  of  iMosher's  instrument  which 
obviates  this  to  a  great  extent.  It  is  better  in  most  cases  to  do  a  trache- 
otomy as  the  chloroform  may  be  administered  through  the  tracheal  canula 
bv  means  of  a  simple  piece  of  rubber  tubing  one  end  of  which  is  fitted  into 
the  tracheal  canula,  while  the  other  end  has  tied  over  its  extremity  a  tuft 
of  gauze  upon  which  the  chloroform  is  poured.  Used  with  a  tracheotomy, 
the  Mosher  instrument  has  the  advantage  of  closing  the  laryngeal  orifice 
so  that  tamponade  of  the  larynx  is  unnecessary,  or  if  tamponade  be  needed 
the  instrument  serves  to  hold  the  previously  placed  tampon  in  place. 

In  deeper  portions  of  the  esophagus  palliative  treatment  will  greatly 
prolong  life  and  relieve  pain.  When  stenosis  threatens  to  interfere  with 
nutrition  the  esophagoscope  is  introduced  and  the  narrowed  lumen  dilated, 
as  described  in  reference  to  cicatricial  stricture.  Tlie  ordinary  flexible 
bougie  should  never  be  used  except  after  the  esophagoscope  has  deter- 
mined the  absence  of  ulceration  or  weakening  of  the  esophageal  wall. 

Benign  Neopt^asms  of  the  Esophagus. 

Benign  neoplasms,  when  large  enough,  produce  esophageal  stenosis. 
In  many  instances,  however,  they  will  be  discovered  quite  accidentally. 
In  this  connection,  however,  it  must  be  remembered  that,  at  the  present 
dav,  slight  difficulty  or  inconvenience  in  swallowing  is  either  absolutely 
ignored  or  labelled  "neurasthenia"  or  "globus  hystericus,"  and  dismissed. 
Such  a  thing  as  examining  the  case  with  an  esophagoscope  does  not  seem 
to  occur  to  the  clinician's  mind.  When  the  neglected  subject  of  esopha- 
geal disease  receives  its  merited  study,  benign  tumors  will  be  found  to  be 
less  infrequent  than  is  at  present  supposed. 

Edematous  polypus  has  been  observed  but  is  rare.  The  most  fre- 
quent benign  tumors  are.  papillomata,  fibromata,  myomata,  fibromyomata, 
mixomata,  angiomata,  lipomata,  adenomata  and  cystomata. 


BHXIGX  MiOrL.ISMS  OJ-  THE  IlSUI'U .IGUS.  11.'? 

The  base  of  a  benign  ,u;n>\vth  is  never  indurated :  though  we  must  be 
on  our  guard  against  diagnostic  error  in  case  of  its  occurring  at  the  site 
of  a  scar. 

The  naked  eve  diagnosis  of  benign  tumors  is  only  possible  when  they 
are  observed  to  have  long,  distinct  pedunculi.  Malignant  ncoplasmata 
rarely,  if  ever,  occur  ni  this  form.  All  sessile  growths,  whether  ulcerated, 
fungating  or  smooth,  can  only  be  diagnosticated  with  certainty  by  the  aid 
of  the  microscope.  The  removal  of  a  specimen  is  always  justifiable.  No 
hemorrhage  need  be  feared,  if  one  condition  be  excluded,  namely,  vari- 
cosities of  the  esophageal  vessels.  Even  in  such  a  case  it  is  doubtful  if 
any  hemorrhage  will  occur  that  will  not  yield  to  the  eating  of  ice  cream,  or 
the  swallowing  of  pieces  of  ice. 

Treatment.  All  benign  tumors  of  the  esophagus  demand  removal. 
Tlie  possibility  of  their  undergoing  malignant  degeneration  is  disputed, 
but,  while  it  is  true  that  cells  never  change  their  type,  the  benign  neoplastic 
tissue  is  more  liable  than  normal  tissue  to  become  the  site  of  a  malignant 
neoplasm. 

For  removal,  strong  forceps  are  necessary,  especially  in  case  of  pe- 
dunculated tumors.  Necessarily  the  pedunculi  are  tough  and  strongly 
attached,  else  the  growth  would  be  detached  and  swept  downward  by  the 
swallowed  food.  It  is  necessary  as  a  rule  to  bite  out  the  mucosa  where 
the  peduncle  is  attached,  not  only  because  it  is  safer  than  the  severe  trac- 
tion necessary  to  tear  away  the  growth,  but  to  prevent  repullulation.  This 
is  illustrated  in  the  following  case : 

Mr.  P.,  aged  36  years,  was  referred  to  the  aiitlmr  by  Dr.  Heard  for  vague 
and  indefinite  throat  symptoms,  which  would  certainly  not  have  aroused  any 
suspicion  of  esophageal  disease  in  a  mind  not  particularly  bent  toward  the 
subject.  He  said  his  throat  "bothered"  him,  he  had  some  "throat  trouble"  and 
like  indefinite  expressions  of  his  unlocated  sensations.  There  was  some  cough, 
also  occasional  hoarseness.  Examination  with  the  laryngoscope  revealed  a 
chronic  laryngitis,  nothing  more.  Examination  of  the  upper  end  of  the  esopha- 
gus with  the  laryngeal  speculum  revealed  whitish  granular  tumor  attached  by  a 
pedicle  three  centimeters  in  length.  (Eig.  12,  Plate  III.)  The  pedicle  was  at- 
tached about  two  centimeters  below  the  level  of  the  inlerarytenoid  space.  Upon 
a  subsequent  e-xamination  with  the  laryngeal  mirror  the  growth  was  seen  lying 
in  the  inlerarytenoid  space  (Fig.  9,  Plate  III.).  The  growth  was  certainly  not 
there  at  the  first  examination  with  the  laryngeal  mirror.  The  mystery  was  ex- 
plained, however,  when  the  patient  was  told  to  swallow,  and  upon  re-examina- 
tion the  tumor  was  nowhere  to  be  seen.  The  long  pedicle  permitted  the  tumor 
to  rise  above  the  introitus  like  a  floating  buoy  above  its  anchorage,  but  in 
swallowing  the  growth  was  carried  below  the  inferior  constrictor.  With  the 
assistance  of  Dr.  Heard,  the  neoplasm  was  removed  under  local  anesthesia  by 
direct  inspection  through  the  tubular  speculum  (Fig.  6).  The  peduncle  was 
found  of  such  a  tough  fibrous  nature  that  the  esophageal  wall  was  pulled  into 
the   mouth   of   the   speculum,   without    tearing   away.     The   cup-shaped   forceps 


114  SPASTIC  STENOSES  OF  THE  ESOPHAGUS. 

(Fig.  24)  were  then  used  to  bite  out  the  esophageal  wall  to  which  the  peduncle 
was  attached.  The  wound  healed  promptly  and  si.x  months  later  there  was  no 
sign  of  recurrence.  The  growth  was  examined  by  Dr.  Jonathan  Wright,  who 
pronounced  it  fibroma  papillare. 

This  case  is  interesting  as  showing: 

1.  The  absence  of  symptoms  associated  with  small  esophageal  neo- 
plasms. 

2.  The  likelihood  of  overlooking  such  conditions. 

3.  The  necessity  of  examination  of  the  esophagus  in  all  doubtful 
throat  cases. 

4.  The  ease  with  which  the  upper  end  of  tlie  esophagus  can  be  ex- 
amined, and  the  ease  of  removal  of  neoplasms  therefroni,  with  the  aid  of 
the  tubular  speculum. 

5.  Tlie  advisability  of  excision  of  benign  growths  with  the  cupped 
forceps,  as  compared  to  evulsion  with  serrated  forceps. 

Many  benign  growths  have  a  strong  tendency  to  recur.  They  do  not 
infiltrate,  hence  are  not  malignant,  but  they  repullulate  in  a  most  stubborn 
manner  if  any  portion  is  left. 

Spastic  Stenoses  of  the  Esophagus. 

Cardiospasm,  as  its  name  implies,  is  applied  to  a  condition  of  spas- 
modic closure  of  the  cardiac  orifice  of  the  stomach.  It  is  applied,  how- 
ever, to  spasmodic  closure  of  the  esophageal  lumen  without  limitation 
strictly  to  the  cardia.  The  cardia  is  not  a  genuine  sphincter,  though  Hyrtl 
has  demonstrated  circular  fibres.  The  prevention  of  regurgitation  is  prob- 
ably as  mucli  a  ki'.iking  of  the  esophagus  due  to  expansion  and  upward 
movement  of  the  fundus  ventriculi  as  to  any  sphincter-like  action  at  the 
cardiac  orifice.  There  is,  however,  a  distinct  sphincter-like  action  at  the 
hiatus  esophageus.  Wherever  future  study  may  demonstrate  the  seat  of  the 
spasm  to  be,  there  can  be  no  doubt  of  its  occurrence.  Many  observers 
have  seen  it.  In  all  three  of  the  author's  cases  it  occurred  in  the  abdom- 
inal esophagus  between  the  cardia  (as  indicated  by  the  mucosa)  and  the 
hiatus.  In  two  of  these  cases  it  was  associated  with  peptic  ulcer  of  the 
abdominal  esophagus.  It  disappeared  completely  while  the  patient  was 
under  deep  general  anesthesia.  It  was  associated  with  slight  dilatation  of 
the  superjacent  esophagus.  A  number  of  competent  observers  have  noted 
this  dilatation  of  a  very  marked  degree. 

Phrenospasm  is  a  name  given  by  the  author  to  a  closure  of  the  esoph- 
agus at  the  hiatus  esophageus  by  a  tonic  spasm  of  the  neighboring  portion 
of  the  diaphragm.  It  is  frequently  seen  in  passing  the  long  esophagoscope 
or  gastroscope  without  anesthesia  or  in  withdrawal  of  the  instrument  after 
the  tube  mouth  has  retreated  from  the  hiatal  portion  of  the  esophagus. 
Frequently  in  the  absence  of  anesthesia,   the  instrument  is   clamped   so 


COMPRESSION  STENOSES  OP  THE  ESOPHAGUS.       115 

tightly  in  this  plircnospasni  that  the  niovoments  of  the  tube  are  hindered. 
It  disappears  completely  during  the  relaxation  of  deep  general  anesthesia. 
This  complete  disappearance  of  the  obstruction,  along  with  a  normal  yield- 
ing wall  and  a  normal  mucosa  establishes  the  diagnosis  absolutely.  It  is 
almost  invariably  associated  with  dilatation  of  the  portion  of  the  eophagus 
immediately  above  it,  just  as  organic  stricture  is. 

Esophagospasni  or  esophagismus  is  usually  the  condition  found  m 
globus  hystericus.  It  is  associated  with  great  difficulty  in  introducing  an 
esophagoscope  under  local  anesthesia,  but  it  disappears  promptly  under 
deep  anesthesia,  when  the  esophagoscope  may  be  passed  freely  up  and 
down  the  esophagus,  revealing  a  wall  of  normal  resiliency,  which  wall 
shows  the  normal  respiratory  excursion,  and  which  is  covered  with  normal 
mucosa.  Occasionally  esophagisnuis  will  be  found  to  be  secondary  to  a 
lesion,  the  most  frequent  lesion  being  a  simple  ulcer. 

The  treatment  of  spastic  conditions  of  the  esophagus  may  be  pallia- 
tive or  curative.  Palliative  treatment  consists  in  the  use  of  iced  liquid 
food  in  some  instances,  of  hot  liquids  in  others.  Drugs  as  morphin  and 
cocain  have  an  effect,  but  their  use  should  be  avoided.  Curative  treat- 
ment consists  in  the  cure  of  ulcers  if  present,  in  the  application  of  gal- 
vanism with  the  olive-pointed  electrode,  and  in  bouginage.  After  the 
esophagoscope  has  demonstrated  the  normality  of  the  esophageal  wall,  the 
daily  passage  of  the  flexible  esophageal  bougie  by  the  patient  will  establisii 
a  cure  after  extreme  tolerance  to  the  bougie  is  developed.  Retrograde  in- 
strumental dilatation  is  used  in  extreme  cases,  but  the  esophagoscopic  di- 
latation is  the  most  useful  in  abolishing  the  hypersensibility  of  the  esoph- 
agus, which  is  the  chief  factor  in  many  cases. 

Compression  Stenoses  of  the  Esophagus. 

Compression  stenoses  of  the  esophagus  are  produced  by  many  differ- 
ent conditions.  Hypertrophic,  inflammatory,  neoplastic  and  exudative 
diseases  of  adjacent  tissues  may  compress  the  esophagus.  The  most  fre- 
quent conditions  are:  struma,  glandular  infiltrations,  mediastinal  or  cer- 
vical tumors,  aneurysms,  pleural  and  pericardial  effusions,  abscesses,  spinal 
deformities,  etcetera. 

The  differential  diagnosis  of  these  conditions  depends  less  upon  end- 
oscopic examination  than  upon  general  clinical  diagnostic  methods.  Tlie 
location  of  the  stenosis  as  measured  esophagoscopically  is  often  an  aid. 
In  aneurysm  the  pulsations  are  diagnostic,  if  the  observer  is  familiar  with 
the  normal  pulsatory  movements  as  observed  in  the  esophagoscope.  The 
radiograph  is  a  very  important  aid  in  diagnosticating  aneurysm  and  some 
forms  of  mediastinal  tumors.  (Figs.  50  and  62.)  In  aneurysm  the  pul- 
sations may  be  seen  fluoroscopically. 


Fill.  62. — Radiogram  showing  location  of  a  malignant  mciliastmal   tumor  produc- 
ing ctanpression  stenosis  of  the  esophagus. 


CHAPTER     XV. 
Non-5tenotic  Diseases  of  the  Esophagus. 

Diverticula. 

A  divcrticulniii  is  a  circumscribed  ectasi?.  of  the  esophageal  wall,  in 
centra-distinction  to  a  dilatation  which  is  a  diffuse  ectasia.  Though  a  di- 
verticulum of  the  esophagus  is  not  in  itself  a  stenotic  disease,  it  is  usually 
associated  with  a  subjacent  stenosis,  which  is  the  chief  factor  in  its  pro- 
duction, lliis  form  is  called  a  pressure  diverticulum,  because  of  the 
probable  etiologic  influence  of  the  pressure  of  the  esophageal  contents, 
which  the  musculature  is  endeavoring  to  propel.  The  other  form  is  called 
a  traction  diverticulum,  being  due  tc  traction,  as  by  an  adhesion,  externally 
on  a  circumscribed  portion  of  the  esophageal  wall. 

The  esophagoscopic  picture  is  not  as  clear  as  might  be  at  first  sup- 
posed, though  the  diagnosis  can  be  made  in  every  case  bv  careful  explora- 
tion. The  possibility  of  the  presence  of  a  diverticulum  must  be  borne  in 
mind  in  every  case  of  esophagoscop}-.  ^^'hen  the  esophagoscope  enters 
the  diverticulum  the  orifice  of  the  sub-diverticular  esophagus  is  usually  not 
noticed.  The  tube  mouth  comes  against  a  flat  surface  which  is  usually 
mistaken  for  a  strictural  or  neoplastic  stenosis.  The  tube  is  withdrawn 
and  yet  no  orifice  is  seen.  Often  it  cannot  be  found  until  regurgitation 
forces  some  fluid  through,  or  forms  one  or  more  bubbles.  The  orifice  is 
usually  very  small,  often  slit  like,  and  hidden  by  a  fold  or  band.  To 
favor  regurgitation,  the  patient,  if  under  general  anesthesia,  should  be 
allowed  to  come  out  partially.  The  bottom  of  the  diverticulum  is  usually 
chronically  inflamed  as  shown  in  Fig.  5,  Plate  III,  drawn  from  one  of  the 
author's  ca.ses.  This  chronic  inflammation  is  probably  due  to  the  pres- 
ence of  food,  which  is  not  well  tolerated  by  the  esophagus.  The  normal 
esophagus  endeavors  to  rid  itself  of  everything,  even  its  own  secretions, 
by  upward  or  downward  expulsion.  Frequently  the  diverticulum  will  be 
found  full  of  secretions,  but,  with  the  aspirator  attached  to  the  esophago- 
scope, (Figs.  17  and  18,)  the  latter  is  slowlv  inserted  and  the  secretions 


118  DILATATION  OF  THE  ESOPHAGUS. 

removed  ahead  of  the  tuhe  in  a  manner  that  eliminates  all  trouble  from 
this  source  during  the  examination.  Large  masses  of  food,  sometimes 
present,  may  be  removed  with  the  forceps. 

The  treatment  of  diverticula  is  mainly  surgical.  Dilatation  of  the 
sub-diverticular  stricture  will  produce  a  symptomatic  cure  and  occasion- 
ally some  recession  of  the  size  of  the  diverticulum  may  thus  be  brought 
about,  if  the  strictured  passage  be  kept  open.  If  so  located  that  external 
surgery  is  of  aid,  a  radical  cure  may  be  brought  about.  Such  cases  have 
been  reported  by  Depage,  Kocher,  Bilroth,  Goris,  and  others. 

DlL.^TATlOX  OF  THE  EsOPHAGUS. 

Dilatation  is  a  diffuse  ectasia  of  the  esophageal  wall,  in  coiitra-dis- 
tinction  to  a  diverticulum  which  is  a  circumscribed  ectasia. 

The  most  common  form  is  the  spindle  shaped  esophagus. 

It  is  very  rare  in  tiie  upper  portion  of  the  esophagus.  It  occurs  in 
three  classes  of  cases : 

1.  Those  in  vvhich  there  is  below  the  dilatation  an  anatomic  stricture 
which  is  evidently  its  cause. 

2.  Those  in  which  there  is  a  spasmodic  stricture,  usually  a  phreno- 
spasm  or  cardiospasm  below  the  dilatation. 

3.  Those  in  which  there  is  no  stricture  anatomic  or  spastic  demon- 
strable, and  which  are  supposed  to  be  due  to  atony  of  the  esophageal  wall. 
There  is  every  likelihood  that  there  has  existed  at  some  previous  time  a 
cardiospasm  or  a  phrenospasm. 

Various  clinical  and  chemical  methods  of  differential  diagnosis  be- 
tween diffuse  dilatation  and  diverticulum  have  been  advocated  from  time 
to  time,  but  none  of  them  compare  in  accuracy  with  the  simple  procedure 
of  esopliagoscopy,  by  which  we  put  a  tube  down  and  actually  see  the  con- 
ditions present. 

The  esophagoscopic  picture  in  dilatation  is  unmistakable.  In  the 
normal  esophagus,  the  walls  are  visible  at  all  times ;  the  lumen  enlarging 
upon  inspiration,  but  never  to  such  an  extent  that  the  walls  are  not  visible. 
In  dilatation,  on  the  contrary,  during  inspiration  the  entire  wall  disappears 
and  the  tube  end  is  seen  to  be  in  a  large  cavity,  the  walls  of  which  are 
ballooned  out.  The  upper  wall,  if  the  patient  be  in  dorsal  decubitus,  may 
sag  downward,  and  it  will  be  noticed  that  to  bring  the  lower  (posterior) 
wall  into  view  the  tube  mouth  must  be  lowered  quite  a  distance.  Later- 
ally the  enlargement  of  the  lumen  is  equally  apparent  upon  a  lateral  move- 
ment of  the  tube  mouth.  Of  course,  this  description  applies  to  extreme 
degrees  of  dilatation.  All  sizes  and  stages  of  dilatations  are  met  with 
and  the  lesser  degrees  may  raise  the  question  of  the  border  line  between 
normalitv  and  disease. 


DILATATION  OF  THE  P.SOPHAGUS.  119 

The  dilatation  is  not  always  concentric  and  it  is  not  always  possible 
to  determine  whether  it  is  concentric  or  not.  The  possible  extent  of  lat- 
eral drag  in  all  directions  is  some  criterion,  but  this  varies  within  the 
limits  of  health,  and  considerable  experience  in  esophagoscopy  is  neces- 
sary to  determine  the  degree  of  eccentricity  of  the  dilatation,  and,  indeed, 
the  presence  of  a  dilatation,  if  the  dilatation  be  of  very  slight  degree. 

Dilatations,  if  of  any  size,  usually  contain  food  particles,  and  also 
more  secretion  than  the  normal  esophagus,  due  to  the  chronic  turgescence 
and  inflammation  of  the  mucosa.  TTie  accumulation  is  due  rather  to  the 
obstruction  below,  and  to  the  motor  insufficienc}-  than  to  the  mere  dilata- 
tion per  se.  The  mucosa  often  shows  dilated  capillaries  and  occasionally 
erosions.  In  cases  associated  with  cicatricial  stenosis,  cicatrices  may  be 
seen.  In  pushing  the  tube  on  downward  the  presence  of  the  subjacent 
stenosis  and  its  character,  whether  anatomic,  cardiospastic,  or  phrenos- 
pastic  will  be  determined  as  before  described  when  speaking  of  stenotic 
diseases. 

A  tumor  more  frequently  malignant  than  benign  may  exist  in  the 
dilatation.  Ulceration,  benign  or  malignant,  occurs.  In  cardiospastic 
and  phrenospastic  dilatations,  the  mucosa  is  very  much  reddened,  especially 
in  the  upper  two-thirds  of  the  dilatation.  In  the  lower  third,  it  is  usually 
paler  and  the  dilated  branching  capillaries  are  particularly  noticeable  at 
the  site  of  the  spastic  stricture.  Below  this  the  mucosa  is  sometimes 
noticed  to  fold  in  over  the  end  of  the  tube  in  transverse  folds. 

The  differential  diagnosis  between  spasmogenic  dilatations  and  those 
resulting  from  anatomic  stricture  is  easily  made  by  the  determination  of 
the  presence  or  absence  of  an  anatomic  stenosis.  TTie  differential 
diagnosis  between  spasmogenic  and  atonic  dilatations,  if,  indeed  the 
latter  kind  ever  exists  alone,  is  difficult.  As  previously  stated,  tlie 
author's  belief  is  that  the  so-called  atonic  dilatation  is  a  result  of  pre-ex- 
istant  spasmogenic  conditions.  The  differential  diagnosis  between  dilata- 
tion and  a  deeply  situated  diverticulum,  impossible  by  other  methods,  is 
easily  made  esophagoscopically.  If  a  diverticulum  exists,  no  hiatal  slit 
or  cardia  will  be  found,  instead,  the  tube  mouth  will  stop  against  a  lightly 
stretched  wall,  the  bottom  of  the  diverticulum.  The  orifice  of  the  sub- 
diverticular  esophagus  can  be  found  by  careful  search  as  the  esophago- 
scope  is  very  slowly  withdrawn. 

The  treatment  of  dilatations  is  based  upon  eradication  of  the  cause. 
The  subjacent  stenosis,  anatomic  or  spastic  must  be  dealt  with.  If  ana- 
tomic it  is  treated  as  previously  outlined,  by  dilatation,  forcible  or  prefer- 
ably gradual.  The  wearing  of  a  short  tube  or  sound  for  an  hour  or  more 
is  beneficial,  but  the  size  must  be  exactly  determined  so  as  to  cause  some 
dilatation  and  yet  not  too  much.     The  size  should  be  gradually  increased, 


120  INFLAMMATIOX  .IXD  ULCERATION. 

and  a  strong  heavy  braided  silk  cord  must  be  attached  for  removal. 
Electrol\tic  dilatation  of  the  stricture  might  be  tried.  The  inflammation 
and  ulceration  of  the  mucosa  can  be  treated  by  topical  applications,  if 
necessary,  after  the  relief  of  the  dilatogenic  stenosis.  Often  it  will  not  be 
necessary. 

Inflammation  and  Ulceration  of  thic  Esophagus. 

Acute  csophagitis  arising  from  any  cause  save  traumatism  is  a  posi- 
tive contra-indication  to  esophagoscopy.  Where  due  to  traumatism, 
esophagoscopv  is  also  contraindicated  save  where  the  traumatic  agent,  as 
a  foreign  body,  is  still  in  the  esophagus.  In  this  case  it  should  be  re- 
moved at  once. 

The  esophagoscopic  appearances  are  those  of  an  acute  mucosal  in- 
flammation elsewhere.  Intense  congestion  of  the  mucosal  capillaries  pro- 
duces as  intense  reddening,  which  may  be  diffuse  or  circumscribed  ac- 
cording to  origin.  If  the  inflammation  is  more  intense  in  some  point  than 
others,  a  flecked  or  patchy  appearance  may  be  observed.  After  the  in- 
cipient stage  is  passed,  if  serous  effusion  takes  place,  the  mucosa  assumes 
the  edematous  semitranslucent  appearance  often  seen  in  the  larynx. 
Vessels  are  not,  as  a  rule,  visible  in  acute  inflammation. 

Acute  inflammation  is  easily  diagnosticated,  but  care  must  be  taken 
that  we  do  not  overlook  associated  lesions.  For  instance,  a  nniral  esopha- 
geal carcinoma  may  be  intruding  the  overlying  mucosa  into  the  lumen, 
wherewith  the  irritation  thus  resulting,  the  mucosa  may  give  the  ap- 
pearance of  acute  inflammation. 

Chronic  csopliagitis  may  follow  acute  csophagitis,  or,  more  fre- 
quentlv.  it  mav  be  the  result  of  long-continued  irritation  of  food  particles, 
mucus,  ])us,  etcetera,  which  are  entrapped  in  the  esophagus  by  spastic  or 
anatomic  stenoses,  dilatations  or  diverticula,  which  prevent  the  esophagus 
from  immediately  emptying  itself,  which  it  always  does  promptly  under 
normal  conditions. 

Uncomplicated  simple  catarrhal  inflammation  of  the  esophagus 
exists,  commonly  in  alcoholics,  due  to  general  engorgement  and  vaso- 
motor relaxation  from  the  systemic  action  of  the  alcohol,  and  also  from 
the  local  irritant  eft'ect  of  the  insufficiently  diluted  alcohol  upon  the 
esophageal  mucosa.  Catarrhal  inflammations  also  result  from  other 
causes  local  and  systemic,  the  latter  usually  diathetic. 

The  esophagoscopic  appearances  are  usually  a  dirty  gray,  or  grayish 
white,  or  pale  red,  sometimes  mottled,  mucosa  streaked  with  vessels,  and 
covered  with  a  tenacious  mucus  which  is  sponged  away  with  difficulty. 
(Fig.  5,  Plate  III.) 


ULCliRATlOX  or  rill-.  JiSUI'JLlGUS.  1-il 

Ulceration  is  often  seen.  I'lcers  may  be  divided  into  two  general 
classes : 

Those  above  and  those  lielow  the  hiatus.  'I  be  npjier  class  may  be 
due  to  the  same  causes  as  tlie  innammation.  abrasions  and  the  like,  or  they 
may  be  due  to  the  intensity  of  the  inflammation  itself,  resulting  in  a 
localized  tissue  necrosis.  They  may  be  due  to  a  local  thrombosis  of  em- 
bolic or  other  origin.  Those  occurring  in  tyjihoid  fever  are  usually  of 
thrombotic  pathology.  Epithelial  erosions  frequently  occur  in  profound 
toxemic  states  in  the  course  of  the  general  infections. 

Deep  ulcerations  occur  in  syphilis  more  often  than  is  realized,  as 
unless  the  resultant  cicatrix  is  sufficient  to  interfere  seriously  with  de- 
glutition the  lesion  is  overlooked,  as  it  is  usually  painless.  Deep  ulcera- 
tive lesions  occur  in  tuberculosis,  and  is  very  frequently  overlooked.  As 
much  as  four-fifths  of  the  esophagus  has  been  known  to  be  involved 
without  an  esophageal  disease  having  been  suspected.  The  author  has 
seen  a  great  many  cases  where  the  dysphagia  and  odynphagia  present 
were  attributed  to  the  concomitant  laryngeal  tubercular  lesion.  Tuber- 
culosis of  the  esophagus,  like  that  of  the  larynx,  is  usually  secondary  to 
a  pulmnnarv  lesion,  the  infection  being  conveyed  by  the  sputum:  or  it 
mav  occur  by  continuative  extension  from  a  tubercular  bronchial  gland 
or  vertebra.  It  may  occur  by  contiguous  extension,  as  for  instance  on 
the  posterior  wall  from  contact  of  the  tubercular  larynx.  (Fig.  6, 
Plate  III.) 

Peptic  ulcer.  Ulcers  occurring  below  the  hiatus  esophageus  are  usual- 
ly classed  as  peptic  ulcers  and  often  bear  a  strong  resemblance  to  peptic 
ulcer  of  the  stomach.  They  are  often  attributed  to  functional  insuf- 
ficiency of  the  cardia.  but  the  author's  opinion  elsewhere  stated  is  that  the 
functional  closure  of  the  upper  end  of  the  stomach  is  due  to  a  kinking  of 
the  esophagus  at  the  hiatus,  due  to  pressttre  of  the  gastric  fundus  and  the 
peri-hiatal  structures.  This  permits  the  stomachal  contents  frequently  to 
invade  the  lower  end  of  the  esophagus.  Whatever  may  be  the  ]:)athology 
of  peptic  ulceration  of  the  esophagus,  it  has  a  pathology  essentially  dif- 
ferent from  that  of  other  mucosal  ulcerations.  In  whatever  they  may 
consist  these  differences  are  participated  in  to  some  extent  by  duodenal 
and  lower  esphageal  ulcerations.  It  is,  therefore,  logical  to  suppose  that 
the  stomach  contents  are  a  factor  in  the  production  of  these  ulcerations. 

Ulcerations  of  [jathology  other  than  that  of  those  enumerated  occur 
rarelv.  When  an  unexplainable  ulcer  is  found,  especially  if  fungating  a 
buried  foreign  body  should  be  thought  of. 

The  treatment  of  inflammation  and  ulceration,  consists  in  removal  of 
the  cause,  be  it  local  or  general.  Then  topical  applications  of  argentic 
nitrate,  arg^rol,   glvcerole  of   iodin   or  of  tannin   will   be  beneficial.     If 


1-22  NEUROSES  OF  THE  ESOPHAGUS. 

the  lesion  be  circumscribed,  the  apphcations  should  be  made  with  a  dossil 
of  cotton  on  a  sponge  holder.  In  the  treatment  of  peptic  ulcer  the  gen- 
eral methods  advocated  for  gastric  ulcer  are  useful,  but  they  are  of  only 
secondary  importance  to  the  direct  application  of  silver  nitrate,  argyrol, 
etcetera,  to  the  ulcer  under  direct  inspection  of  the  eye,  looking  through 
the  esophagoscope.  Bismuth  powder  may  be  blown  directly  upon  the 
ulcer  by  means  of  the  extra  drainage  tube.  The  ulcerated  surface  should 
first  be  cleaned  off  with  a  dossil  of  cotton  dipped  in  hydrogen  perqxid 
solution.  There  is  no  danger  of  either  perforation  or  of  hemorrhage  from 
these  procedures  if  the  manipulations  be  gentle,  and  guided  by  the  eye 
through  the  esophagoscope.  There  is  great  danger  from  blind  poking 
with  a  bougie,  especially  in  these  lowly  situated  ulcers,  as  reflex  spasm 
from  the  presence  of  the  tube  is  apt  to  close  up  the  lumen  ahead. 

Neuroses  of  the  Esophagus. 

Spastic  neuroses  have  already  been  touched  upon. 

Sensory  neuroses,  including  hyperesthesia,  anesthesia,  and  para- 
esthesia  exist,  but  careful  esophagoscopic  search  often  reveals  an  anatomic 
basis,  such  as  an  ulcer,  a  scar,  or  an  inflammatory  area,  in  cases  in  which 
theretofore  a  diagnosis  of  neurosis  had  been  made  on  the  anamnesis  and 
sounding.  The  symptoms  complained  of  are  usually  of  a  vague  char- 
acter as  of  contraction,  itching,  sticking,  pricking,  uneasiness  or  irritation, 
or  of  a  foreign  body  or  crawling  insect. 

Exclusive  of  hysteria,  sensory  neurosis  of  the  esophagus  will  be  found 
exceedingly  rare.  In  almost  all  cases  of  anamnestic  similarity  will  be 
found  to  be  anatomic,  not  purely  neurotic  in  origin. 

The  treatment  is  by  very  mild  galvanism  locally,  using  the  inter- 
rupted current,  and  general  treatment  and  regime  as  deemed  best  by  the 
internist  or  neurologist. 

Paralysis  and  Pareses  oe  the  Esophagus. 

Tlie  symptoms  of  defective  inervation  of  the  esophagus  point  very 
markedly  to  esophageal  trouble.  All  solid  food  is  swallowed  with  diffi- 
culty ;  fluids  are  usually  swallowed  freely.  In  some  cases  even  fluids  re- 
fuse to  go  down  except  in  very  small  quantities.  There  are  pain  back  of 
the  sternum  after  eating,   regurgitation  of  food  and  mucus. 

With  a  history  of  trouble  of  this  magnitude  one  is  apt  to  expect 
the  esophagoscope  to  meet  with  obstruction  to  its  passage.  Exactly  the 
reverse  is  the  case.  It  readily  enters  the  introitus  and  passes  on  down 
into  the  stomach  without  the  slightest  resistance,  going  as  readily  without 
an  anesthetic  as  it  would  in  the  normal  esophagus  with  the  deepest  general 


PARALYSIS  OF  THE  ESOPHAGUS.  123 

anesthesia.  Tlius  the  (Hagnosis  is  estaWished.  In  spastic  stenoses  we 
find  the  spasm  if  no  anesthetic  be  used,  while  in  anatomic  stenoses  we 
find  a  stricture  uninfluenced  by  anesthesia.  The  paralysis  may  be  ocularly 
demonstrated  by  Stark's  pill  experiment.  With  the  aid  of  an  csophago- 
scope  and  forceps  a  pill  or  capsule  is  deposited  in  the  esophagus  at  a  dis- 
tance of  27  cm.  from  the  upper  teeth.  If  the  peristalsis  be  normal  the  pill 
will  be  carried  downward  into  the  stomach ;  if  the  pill  remains  where 
placed  it  demonstrates  a  paralysis  or  at  least  an  abnormal  feebleness  or 
atony  of  the  esophageal  musculature. 

The  causes  of  paralytic  conditions  of  the  esophagus  include  central 
and  peripheral  nerve  lesions,  most  common  being  bulbar  paralysis  and 
neuritis,  including  diptheritic,  alcoholic  and  lead  palsies. 

TTie  treatment  of  these  conditions  is  usually  not  esophagoscopic,  but 
general.      Local  electrical  applications  are  beneficial  adjuncts. 

It  must  be  confessed  that  we  know  but  little  of  esophageal  neuroses 
and  much  remains  to  be  studied  esophagoscopically.  For  this  purpose 
all  clinical  material  should  be  availed  of,  and  experimentally  the  dog  may 
be  used,  double  vagotomy,  being  done  under  chloretone  and  morphia 
anesthesia. 


CHAPTER    XVI. 
Foreign  Bodies  in  the  Lsophagus, 

Considering  the  brilliant  achievements  of  esophagoscopy  in  the  re- 
moval of  foreign  bodies  from  the  esophagus,  it  is  time  to  pronounce  the 
prevalent  use  of  the  sound,  the  vertebrated  forceps,  the  coin  catcher,  the 
bristle  and  the  sponge  probangs  obsolete,  dangerous,  unsurgical  and  ut- 
terly unjustifiable.  There  are  numerous  cases  on  record  of  fatal  results 
from  their  use,  and  there  are  many  times  as  many  cases  that  have  never 
been  reported.  The  author  has  seen  in  consultation  two  fatal  cases  from 
attempted  extraction,  both  unsuccessful.  In  one  case  a  sound  (with 
stilet)  had  been  pushed  through  the  thoracic  esophageal  wall  in  an  efifort 
to  push  a  peach  stone  downward,  and  in  the  other,  the  esophagus  had 
been  ripped  open  by  a  coin  catcher.  A  number  of  instances  of  shock 
from  esophageal  wounds  have  been  observed  by  the  author,  and  many 
cases  of  minor  wounds.  (Fig.  lo,  Plate  III.)  Even  the  sound  may  make 
dangerous  wounds  by  forcing  a  sharp  or  pointed  body  through  the  eso- 
phageal wall.  Equally  erroneous  and  dangerous  is  the  practice  of  making 
light  of  the  patient's  fears,  and  the  telling  him  that  if  he  has  swallowed 
anything,  it  will  go  on  downward  without  doing  any  harm.  Some  things 
will,  and  others  will  not.  Pointed  and  sharp  objects,  as  a  rule,  lodge, 
perforate  and  often  prove  fatal.  Smooth  round  objects,  such  as  intuba- 
tion tubes,  usually  pass  without  difficulty.  Coins  are  very  prone  to  lodge, 
though  usually  in  a  vertical  position,  so  that  they  allow  food  to  pass.  In 
one  case  of  the  author's  a  penny  remained  in  the  esophagus  of  an  i8- 
months-old  child  for  two  months  and  eroded  through  into  the  trachea. 

The  anamnesis  is  unreliable  and  misleading.  The  patient  often  does 
not  know  that  he  has  a  foreign  body,  but  comes  for  difficulty  in  swallow- 
ing. In  infants  the  swallowing  of  the  foreign  body  may  not  have  been 
observed.  Tlie  little  patient  is  taken  to  the  physician  for  regurgitation  of 
food,  or  as  in  one  case  of  the  author's  for  respiratory  difficulty,  which 
arose  from  perforation  of  the  foreign  body  from  the  esophagus  forward 
into  the  trachea.      Often  patients  will  sav  thcv  no  longer  feel  it  when  the 


ESorii.nnTis.  i-5 

foreign  body  is  still  in  situ.    Still  nmrc  mislca.ling  is  the  patient's  localiza- 
tion.     The  corpus  delicti  is  very  rarcl>   located  where  the  patient  assures 


us  it  is. 


The  Roentgen  ray  is  much  more  reliable  and  its  aid  should  be  avaded 
of  in  every  case.  What  has  been  said  in  a  previous  chapter  in  regard  to 
the  rav  in  the  diagnosis  of  foreign  bodies  in  the  air  passages,  applies 
equallv  well  in  relation  to  the  esophagus.  It  may  be  well  here  to  em- 
phasize a  statement  there  made.  In  no  case  should  a  negative  radiograph 
deter  one  from  making  an  esophagoscopic  examination,  if  the  anamnesis 
or  the  symptoms  justify  a  suspicion  of  the  presence-  of  a  foreign  sub- 
stance. 

In  a  number  of  instances  the  author  has  been  rewarded  l)>-  success  in 
the  face  of  a  negative  radiograph.  In  other  instances  he  has  found  lesions 
of  the  esophagus  due  to  long  standing  disease  attributed  to  a  supposed 
swallowing  of  a  foreign  bodv.  In  ,Mie  instance  the  patient  complained  of 
the  lodgement  of  a  chicken  boiu-  which  she  located  back  of  the  sternum, 
where  she  could  feel  it  every  time  she  swallowed.  fpon  gastroscopic 
examination  an  old  ulcer  was  found  just  above  the  cardia,  and  another  on 
the  posterior  wall  of  the  stomacli.  As  suggested  bv  Dr.  Clement  Jones, 
who  assisted  at  the  gastroscopy,  a  large  l.iolus  of  food  in  passing  the  ulcer 
had  produced  a  sensation  of  pain  which  had  since  persisted,  and  which  had 
been  wrongly  attributed  to  a  supposed  bone. 

The  matter  of  anesthesia  is  governed  by  rules  elsewhere  given. 
Local  anesthesia  is  sufficient,  though  as  a  rule,  a  general  anesthetic  is 
better  in  all  cases  free  from  respiratory  difficulty,  which  complication  is 
more  frequent  than  might  at  first  be  supposed.  In  ad.lition  to  edema  of 
the  larvnx  from  previous  blind  groping  attempts  at  removal,  there  may  be 
mechanical  obstruction  of  the  trachea  from  pressure  of  a  large  body  or 
from  inflammatory  exudates  in  the  tracheo-esophageal  wall,  or  possibly 
feebleness  of  the  respiratory  movements  from  pressure  of  the  foreign  sub- 
stance or  inflammatory  exudates  upon  the  vagi. 

When  a  case  suspected  of  a  foreign  body  comes  to  the  author,  a 
regular  routine  is  followed.  After  taking  the  history,  the  nasopharynx, 
fauces,  pillars,  tonsils,  the  back  of  the  tongue,  gloss-epiglottic  fossae, 
larvnx.  and  all  parts  of  the  upi)er  air  passages  accessible  are  ex- 
amined with  the  mirror  and  brushed  with  a  cotton  moii.  If  nothing  is 
found  the  case  is  sent  to  a  Roentgenologist  and  a  plate  is  made  (the 
fluoroscope  is  not  used).  If  no  foreign  substance  is  seen  and  the  symp- 
toms and  anamnesis  warrant  the  case  is  esophagoscopized  ;  and,  if  noth- 
ing is  found,  the  trachea  and  larger  bronchi  are  examined  in  some  cases, 
if'"'the  foreign  bodv  supposed  to  be  present  is  small  enough  to  pass  the 
glottis.      If  the  radiograph  shows  the  foreign  bodv  to  be  in  the  thoracic 


116  ESOPHAGOSCOPY  FOR  FOREIGN  BODY. 

esophagus,  there  is  a  great  temptation  to  put  the  esophagoscope  down  at 
once  to  the  point  located.  This  would  be  a  mistake.  The  tubular  specu- 
lum should  first  be  used  to  examine  the  pyriform  sinuses  and  all  the 
neighborhood  of  the  introitus.  The  necessity  of  this  is  shown  by  a  case 
referred  to  the  author  by  Dr.  Pool.  While  we  were  esophagoscopically 
searching  the  thoracic  esophagus  at  the  level  of  the  fourth  dorsal  vertebra, 
where  the  pin  was  when  the  radiograph  was  made  by  Dr.  Boggs,  the  as- 
sistant picked  the  pin  out  of  the  mouth  with  the  fingers.  Possibly  it  had 
been  regurgitated  by  the  retching  incidental  to  the  application  of  the 
local  anesthetic.  Be  this  as  it  may,  it  emphasizes  the  rule  to  examine 
seriatim  all  the  surfaces  from  above  downward.  This  pin  might  have 
escaped  into  the  air  passages.  Another  reason  for  the  rule  is  that  lesions 
weakening  the  walls  or  exposing  vessels  may  exist  coincidentally  or  as  a 
cause  of  the  symptoms  of  a  foreign  body  when  none  exists.  The  only 
safe  and  certain  way  is  by  careful,  orderly  procedure  to  examine  all 
tissues. 

The  technic  of  the  passing  of  the  esophagoscope  is  given  under 
"Gastroscopy."  As  a  rule,  the  finding  of  a  foreign  body  in  the  esophagus 
is  a  very  easy  matter.  It  is  possible,  however,  for  it  to  get  so  buried  in 
the  swollen  mucosa  as  not  to  be  visible.  In  one  case  referred  to  the 
author  by  Dr.  Day  a  double-pointed  pin  (D  Fig.  63)  was  buried  out  of 
sight,  having  penetrated  beneath  the  mucosa  and  having  wandered  from 
the  point  of  entrance.  Even  in  such  a  case  patient  search  is  usually  suc- 
cessful. The  same  may  be  said  of  foreign  bodies  lodged  in  diverticula. 
When  found,  the  foreign  substance  may  be  so  large  that  it  cannot  be  ex- 
tracted through  the  esophagoscope.  In  such  a  case  the  tube,  forceps  and 
the  intruder  are  all  withdrawn  together.  The  foreign  body  may  be  so 
sharp  or  so  angular  or  pointed  that  to  remove  it  involves  serious  risk 
of  wounding  the  esophageal  wall.  If  the  points  cannot  be  covered  by 
withdrawal  into  the  esophagoscope,  the  substance  in  some  instances  may 
be  divided  and  removed  in  sections. 

In  the  case  of  an  open  safety  pin  with  point  downward,  a  hook  or 
forceps  may  be  used  to  draw  it  into  the  esophagoscope.  If  the  point  is 
upward  (Fig.  64),  it  may  be  possible  to  draw  the  point  into  the  tube 
mouth  with  the  forceps,  to  turn  the  pin  with  a  hook  inserted  in  the  ring  of 
the  spring  end.  This,  however,  involves  some  risk  of  forcing  the  point 
through  the  esophageal  wall.  A  safer  plan  is  to  close  the  pin.  The 
credit  of  having  first  done  this  belongs  to  Mosher.  The  ring  of  the 
instrument  (Fig.  27)  is  inserted  and  insinuated  into  position  below  the 
pin  which  is  then  pushed  into  the  ring  with  the  pronged  instrument. 

The  author  has  modified  this  instrument  to  facilitate  its  introduction. 
The  ring  lies  in  the  same  plane  as  the  stem  during  introduction,  and  is 


FOREIGN  BODIES. 


127 


Fig.  C3. — Foreign   bodies  removed   by   esophagoscopy   aud  gastroscopy. 

(From  the  author's  collection.) 

C,  I'in  lemoved  from  esophagus  of  pregnant  woman  aged  23  years.     Cocain. 

F,  Safety  pin  from  esophagus  of  9  mouths'  old  infant.     Chloroform. 

E,  Forceps  jaw  removed  from  the  stomach  of  man  aged  32  years.     Ether. 
A,  Cufl"  bntlon  removed  from  esophagus  of  4  months'  old  infant.     Cocain. 

G.  Joint  of  carpenter's  rule  removed  from  esophagus  of  boy  of  7  years.     Cocain. 


128 


FOREIGN  BODY  IN  THE  ESOPHAGUS. 


turned  to  a  ris^ht  anisic  after  ii  has  reached  a  [xiiiit  below  tlie  pin.  If  the 
ring  of  the  needed  size  for  tlie  narticiihir  ])in  is  too  large  for  introduction 
through  the  esophagoscope.  the  closer  may  be  started  in  first,  and  the 
esophagoscope  "threaded"  over  it,  or  the  esophagoscope  may  be  started 
alongside  the  stem  of  the  closer.  Tn  tlie  latter  case  care  must  be  taken 
that  the  combined  diameters  of  the  closer  and  the  esophagoscope  do  not 
exceed  the  safe  dilatability  of  the  esophageal  lumen. 


Fig.  G4. — Open  .safety  piu  in  osopliagiis 


Part   III. 

GASTROSCOPY. 


CHAPTER    XVII. 
History  of  Gastroscopy. 

\Mien  the  author  first  obtained  gooil  endoscopic  views  of  the  stomach 
he  thought  it  had  never  been  attemjotcd  before.  But  a  search  of  the  hter- 
ature  brouglit  to  hght  several  previous  attempts. 

Nitsc  and  Letter.  The  first  recorded  attem]5t  to  construct  a  gastro- 
scope  was  by  Mr.  Leiter  and  Dr.  Nitze,  whose  names  are  inseparably  con- 
nected with  the  cystoscope.  Both  before  and  after  this  time  attempts  to 
construct  flexible  and  jointed  instruments  containing  optical  apparatus 
failed  in  the  mechanical  stage. 

Tvouvc.  in  1873.  perfected  a  "])olyscope"  (Fig.  65)  with  which  Col- 
lin, of  France,  demonstrated  endoscopically  the  functions  of  the  stomach 


Fig.  (!•■>. — The  "Polyscope"  of  Trouve. 


HISTORY  01'  G.ISTKOSCOI'V. 


181 


of  a  bull,  and  with  whicli  Ledcntn  and  Raynaud  diaiincisticatod  a  cicatri- 
cial stricture  of  the  esophagus  near  the  cardia. 

Mikiilic::.  in  1881,  started  on  the  l)asis  that  a  gastroscope  must  be 
ris^id.  but  after  rejjcated  trials  he  came  to  the  conclusion  that  a  straight 
rigid  instrument  could  not  be  passed  into  the  stomach  on  account  of  the 
physiologic  curve  of  the  vertebral  column,  to  accommodate  his  instrument 
to  which,  he  gave  the  instrument  an  angle  of  150°  at  the  junction  of  the 
ventral  and  middle  thirds.     (Fig.  66.  ]•".)     This  angle  prevented  a  rotation 


Fig.  iii> — .MiUulicz's  gastroscopo. 


of  more  than  180°  within  the  stomach,  so  that  two  complete  instruments 
were  necessary  with  windows  o]iening  in  opposite  directions  as  shown  m 
Fig.  67.  T'o  touch  the  gastric  walls  means  to  fog  the  window  and  dim 
the  image.  The  Mikulicz  gastroscope  was  ^.5  cm.  long  and  14  mm.  thick. 
The  light  was  furnished  bv  a  platinum  loop  at  the  ventral  end  which  shone 
through  a  window  in  the  side  (Fig.  66,  B).  The  loop  was  sup])lied  with 
current  b\-  wires  entering  at  C.  and  was  kept  cool  by  water  circulating 
through  two  canals  in  the  wall  of  the  tube,  the  entrance  and  exit  being 
shown  at  D.  .\  third  canal  in  the  wall  of  the  tube,  with  an  exit  at  L'  was 
for  inflation  of  the  stomach  with  air  pumped  in  at  L.  (  )ne  did  not  look 
directlv  at  the  tissues,  but  an  image  was  projected  outward  through  a  ter- 


132 


HISTORY  OF  GASTROSCOPY. 


restrial  telescopic  optic  apparatus  with  the  aid  of  two  prisms,  one  at  E 
and  one  at  F.  To  prevent  soihng  the  window  during  introduction,  a  sHde 
is  attached  at  H,  operated  by  a  hand-piece  J,  b)'  which  the  window  is  un- 
covered after  the  stomach  walls  are  distended. 

Mikulicz  arrived  at  the  conclusion  that  a  straight  instrument  was 
absolutely  impracticable  ;  that  it  could  be  passed  as  far  as  the  cardia, 
which  he  believed  to  be  located  at  the  eighth  or  ninth  vertebra,  where  it 
encountered  an  insurpassable  obstruction  in  the  subjacent  vertebra.  His 
straight  experimental  staff  never  really  reached  the  cardia  at  all.  What 
he  encountered  was  the  constriction,  anatomic  and  spasmodic,  at  the  hiatus 
diaphragmatis  and  the  subjacent  esophageal  curve.  Later  Mikulicz  tried 
to  adapt  to  gastroscopy  his  method  of  passing  the  esophagoscope,  by 
which,  instead  of  a  mandrin  he  introduced  a  flexible  bougie,  the  distal 


Fin.  67. — Mikulicz's  gastroscope  in  stomach.     Dotted  lines  show  the  necessity  for 
right  and  left  instruments.     Center  instrument  does  not  show  its  bend. 


end  of  which  protruding  lo  cm.  beyond  the  esophagoscope,  piloted  tlie  lat- 
ter in.     He  did  not  succeed  in  thus  piloting  the  gastroscope. 

Mikulicz  used  morphin  anesthesia  and  placed  the  patient  on  a  table 
in  lateral  horizontal  position,  first  one  side  then  the  other,  according  as 
the  right  or  left  gastroscope  was  being  used.  In  quite  a  proportion  of 
cases  Mikulicz  was  unable  to  pass  his  gastroscope  into  the  stomach.  He 
tried  chloroform,  but  states  that  under  partial  anesthesia  the  reflex  irrita- 
bility seemed  to  be  so  much  increased  that  he  could  not  get  his  instrument 
even  into  the  esophagus ;  while  under  deep  anesthesia  he  was  afraid  ta 
pass  it  lest  it  might  prove  dangerous  from  pressure  on  the  trachea, 
larynx  or  other  parts.  Mikulicz's  examinations  were  mostly  on  healthy 
persons,  as  he  thought  the  normal  was  to  be  studied  first,  and  he  seemed 
to  doubt  the  safety  of  examining  the  stomach  in  serious  disease  of  this 
organ.     W  ith   one  exception  he   did  not   record   the   appearance  of   any 


MIKVLICZ'S  GASTROSCOPE. 


133 


lesion   within   the    stomach,   and    his   description    of    the   normal    is   very 


meagre  and  unilhistrated. 


After  1883  no  account  of  the  use  of  gastroscopy  appears  in  literature 

for  12  years,  and  the  procedure  was  evidently  abandoned  by  its  originator. 

Rosenheim,  in  1896,  reported  experiments  with  a  gastroscope  12  mm. 


Fig.  68. — Mikulicz's  gastroscope  iu  situ, 
bility  of  passing  a  straight  instrument. 


Drawing  by  Mikulicz  to  show  impossi- 


in  diameter,  68  cm.  in  length.  It  was  made  up  of  three  concentric  tubes, 
the  inner  (i,  Fig.  69)  being  a  terrestrial  telescope  of  60°,  with  the  addition 
of  a  prism  below  the  objective,  a  different  prism  to  be  substituted  to  inspect 
different  areas  as  shown  in  Fig.  70.  the  optic  tube  being  withdrawn  for 
the  purpose.     External  to  the  optic  tube  is  the  intermediate  or  illuminat- 


134 


ROSENHEI.]rS  .GJSTROSCOPE. 


ing  tube,  containing  a  window,  F,  behind  which  is  the  electric  lamp,  S. 
Above  this  window  is  an  opening  closed  b}-  the  prism  of  the  optic  tube. 
Four  canals  run  in  the  walls  of  this  intermediate  tube  (2,  Fig.  69)  ;  two 
for  water  (CD.)  circulation  to  cool  the  lamp,  (water  at  40°  C  to  prevent 
condensation  on  the  glass  surfaces  being  required)  ;  a  third  canal  for  con- 


3.     t 


Fig.   00. — Itoscnheim's  gastroscope. 
1,  Optical  apparatus.     2,  Cooling  water  jacket.     3,  Casing  to  keep  wimlow  clean 
during  ii.trodiiction.    S,  Lamp.   G,  Itubber  tip.   G.  Rigid  exploratory  staff,  hard  rubber. 


ducting  wires :  and  a  fourth  canal  beginning  at  L  and  ending  below  F, 
for  the  purpose  of  inflating  the  stomach  with  air.  Tlie  external  tube  (3) 
serves  two  purposes ;  a  measure  of  depth  by  its  scale  markings,  and  a 
protector  to  prevent  soiling  of  the  window  and  the  prism  during  introduc- 
tion, the  external  tube  being  turned  after  introduction  so  that  its  windows 


IflsrORV  OF  G.lSTROSCOPy 


135 


mav  correspond  to  those  of  llic  i)]itic  ami  intcrmcclialo  tul)i.s.  all  three  be- 
ing- known  to  be  in  line  when  the  knobs  on  the  external  llans'es  of  all  three 
are  in  line.  The  stativ  (  l-'ii;'.  71  )  holds  the  snpply  and  escape  vessels  for 
cirenlating-  water  and  the  l)attery.  Rosenheim  tried  to  (Hs]iense  with  the 
water  eircnlation,  bnt  the  .^reat  heat  nf  the  platinnm  filament  lamj)  con- 
fined in  a  closed  instrnnient  threateneil  canterization  of  the  nnieosa  if 
lighted  for  longer  than  ten  seconds. 

In  addition  to  the  straight  gastroscope,  Rosenheim  stales  that  in  Si)nie 
cases  the  spiral  twist  of  the  lower  esophagns  required  an  instrument  bent 
at  an  angle  of  i()0°  at  a  point  7  cm.  from  its  distal  extremity  (6,  Fig.  69). 
He  also  used  a  straight  rigid  stai?  of  the  size  of  the  gastroscope  to  ascer- 
tain if  it  were  possible  to  pass  his  gastroscope  in  the  particular  ease,  and 
if  possible  to  nieasnic  the  dist?nce  that  the  gastroscope  will  have  to  be 
introduced.  He  also  used  a  straight  sound  to  overcome  the  reflex  excita- 
liilitv  in  ditficult  cases.     This  straight  sound  could  be  intrdduced  in  only 


Fid    70. — Itusinilu'im".s  ga^troricope  iu   stomach,   showing  need   for   prisui.s   of  dif- 
fei-eut  degrees. 


about  70  per  cent  of  his  eases.  He  found  that  various  bends  and  curves 
were  necessarv  and  in  some  instances  lie  used  a  corkscrew-like  twist, 
throwing  the  longitudinal  axes  of  parts  of  the  instrument  above  and  be- 
low the  bend  out  of  the  same  plane.  A  very  significant'  fact  is  that  after 
the  beak  of  the  instrument  entered  the  stomach  the  straight  part  followed 
readily.  His  whole  trouble  in  introduction  was  that  his  instrument  was 
not  designed  to  be  passed  by  sight.  He  used  cocain  anesthesia  applied 
with  an  esophageal  syringe. 

As  to  results,  Rosenheim  states  that  gastroscopy  is  impossible  in 
tumor  of  the  stomach,  and  that  it  is  contra-indicated  in  ulcer. 

Rcividcof,  in  1889,  reported  results  with  a  modified  Rosenlicini  gas- 
troscope which  he  passed  through  a  previousl)-  introduced  flexible  rubber 
tube. 


136 


HISTORY  OF  GASTROSCOPy. 


None  of  these  early  workers  has  left  us  any  drawing  of  what  he  saw, 
and  the  written  descriptions  are  hopelessly  meagre.  The  procedure  has 
been  entirely  abandoned.  The  cause  for  the  failure  and  abandonment  of 
gastroscopy  may  be  summed  up  in  two  words :     Impractical  instruments. 

At  the  door  of  the  Nitze  cystoscopc  must  be  laid  the  blame  of  the 


practical  failure  of  gastroscopy  up  until  the  present 


The  attempt  to 


adapt  the  cystoscopic  principles  to  the  totally  different  conditions  in  the 


QESORVOIP 


J\ 


BATTERY    ^1       \  WATER 
TUBES 


Fic.  71. — Stativ  for  Rosenheim's  gastroscope. 


stomach  resulted  in  the  misdirection  of  the  earnest,  able,  scientific  efforts 
of  Mikulicz,  Rosenheim  and  Rewidzof. 

T'he  instruments  were  difficult  of  introduction.  The  optic  apparatus 
absorbed  light  and  yielded  a  feeble  image,  which  soon  disappeared  alto- 
gether from  soiling  of  the  window  every  time  it  touched  the  mucosa.  For 
the  same  reason  the  apparatus  could  not  be  greased  for  introduction. 

The  optic  apparatus,  furthermore,  prevented  the  passage  of  the  in- 
struments by  sight,  it  prevented  the  wiping  away  of  secretions  and  the 


HISTORY  OF  GASTKOSCOPY.  137 

probing  of  suspected  areas,  without  wliich  little  or  nothing  can  bo  learned. 
The  stomach  had  to  be  empty,  which  it  never  is.  All  failed  to  recognize 
the  mistake  of  trying  to  see  a  large  field  in  a  dilated  stomach.  The  field 
must  be  traversed  in  the  collapsed  state  of  the  stomach,  fold  by  fold. 
These  things  are  not  said  in  criticism,  for,  while  the  work  of  these  pio- 
neers was  of  no  help  to  the  author,  as  his  work  was  done  before  he  learned 
of  their  lalxirs,  yet  they  have  rendered  great  aid,  as  we  now  know  by  their 
lack  of  success,  tliat  cystoscopic  methods  are  not  adapted  to  gastroscopic 
work.  This  would  certainly  have  been  tried  by  others,  and  nuich  time  and 
thought  consumed  by  some  one.  ]\Iikidicz  himself  recognized  the  com- 
plexity of  his  apparatus.  He  said :  "There  remains  no  doubt  but  that 
the  instruments,  as  well  as  the  method,  furnish  ample  room  for  improve- 
ment and  simplification."  The  simplification,  I  think,  has  now  been 
reached,  though  of  course,  there  is  still  ample  room  for  improvement. 
The  steps  in  the  development  of  gastroscopy  are  these : 
^Mikulicz  determined  one  point,  namely :  that  a  gastroscope  must  be 
rigid,  but  he  gave  it  a  bend. 

Rosenheim  went  a  step  further  and  said  it  must  not  only  be  rigid  but 
should  be  straight,  though  he  failed  at  times  to  introduce  it  without  a 
bend.     Now,  I  think,  we  are  ready  to  add  four  more  dicta: 

1.  Optic  apparatus  must  be  abandoned. 

2.  The  tube  must  be  passed  by  sight. 

3.  Tlie  stomach  must  be  examined  in  a  collapsed  state,  to  permit  of 
mopping,  palpation  with  the  instrument,  probing,  and  combined  endo- 
scopy and  external  palpation. 

4.  General  anesthesia  is  indispensable  to  prevent  retching,  during 
■which  the  diaphragm  clamps  the  tube,  rendering  exploration  impossible. 


CHAPTER    XVIII. 
The  Usefulness  of  Gastroscopy. 

(jastroscopy  is  not  simply  a  feat.  It  has  a  field  of  usefulness  that 
will  increase  as  our  skill  and  knowledge  increase.  Naturally,  the  ten- 
dency of  everyone  is  to  say  that  only  in  the  obscure  cases  will  gastroscopy 
be  needed.  Yet  this  opens  a  gap  for  the  loss  of  the  opportunity  for  an 
early  diagnosis  of  malignancy,  and  pre-cancerons  conditions. 

^^'hen  the  gastroscope  shall  have  reached  its  deserved  recognition, 
patients  will  be  examined  gastroscopically  sufficiently  early  to  give  the 
abdominal  surgeon  a  fair  chance.  Better  still,  a  positive  diagnosis  of 
pre-cancerous  conditions  vviill  be  made  sufficiently  early  to  enable  him  to 
save  lives  now  being  lost  through  reluctance  of  the  patient  to  submit  to  an 
exploratory  operation.  Gastroscopy  is  not  a  substitute  for  exploratory 
celiotomy  in  every  case. 

Every  surgeon  knows  the  number  of  cases  of  malignant  disease  of 
the  stomach  that  are  fatal  because  the  patients  have  refused  an  explora- 
tory operation  in  the  early  curable  stages.  A  large  proportion  of  all  cases 
of  merely  suspected  malignancy  will  refuse  to  be  (as  they  express  it) 
"cut  open  to  see  what  the  matter  is."  They  start  out  to  find  a  man  who 
can  make  a  diagnosis  without  "cutting  them  open,"  and  they  soon  find  one 
who  will  give  them  the  comforting  assurance  that  they  have  no  cancer 
and  only  need  a  little  treatment.  Thus  their  last  opportunity  is  lost.  If, 
however,  it  is  proposed  to  pass  an  instrument  through  the  mouth,  consent 
will  rarely  be  refused,  especially  when  the  patient  realizes  that  one  is 
going  actually  to  sec  the  conditions  present.  Indeed,  the  author  has  been 
begged  in  two  instances  by  hopeless  cases  of  cancer  to  examine  them.  He 
deemed  examination  inadvisable,  lest  their  impending  death  might  be 
attributed  to  the  gastroscope,  which  at  this  stage  should  not  be  subjected 
to  more  than  its  share  of  criticism. 

That  the  diagnosis  of  malignant  disease  of  the  stomach  by  symptom- 
atic and  chemical  data  is  not  always  easy,  even  in  the  later  stages,  is 
shown  by  the  following  quotation  from  Riegel : 


THE  USEFULXESS  OF  GASTKOSCOFY. 


i;!9 


"There  is  another  class  of  cancer  cases  in  which  the  symptoms  that  are 
ordinarily  considered  characteristic  for  carcinoma  are  absent,  but  ,n  wh>ch 
dyspeptic  disturbances,  loss  of  appetite,  belchin;,  and  general  weakness  appear. 

1„  view  of  this,  it  wotild  seem  diffictilt  by  the  common  methods  abso- 
hitelv  to  excltide  carcinoma  in  a  patient  past  thirty  years  of  age.  All 
such  cases  tlien  would  seem  to  justify  gastroscopy,  rather  than  to  be  con- 
fronted with  the  neeessit^■  of  revising  the  diagnosis  later  after  treatment 
on  the  basis  of  a  benign  condition  has  failed  to  cure.  By  that  time  the 
patient  will  have  become  hopelessly  inoperable,  and  his  death  will  be  due 
to  the  lack  of  an  early  diagnosis. 

And  this  from  Satmdby  : 

••Since  the  era  of  stomach  surgery  we  havejearned  how  latent  in   certain 
•cases  the  characteristic  signs  of  cancer  may  be." 

^\■hen  the  diagnosis  is  made  from  a  palpable  tumor,  cachexia  an<l  the 
vomitus.  it  is  useless,  usually,  except  for  in-ognosis.  ■ 

In  carcinoma  of  adjacent  viscera,  as  of  the  spleen,  where  the  healtliy 
stomach  wall  is  displaced,  but  not  infiltrated,  the  normal  stomach  folds 
visible  in  the  ^astroscope  will  demonstrate  the  uninvolved  condition  of  the 
stomach  and  thus  aid,  for  instance,  in  the  differential  diagnosis  between 
tumor  of  the  spleen  and  tumor  of  the  stomach. 

I„  considering  the  possibilities  of  gastroscopy,  the  occurrence  of 
tumors  other  than  carcinomata  and  sarcomata  must  not  be  forgotten. 
The  gastroscope  renders  it  possible  to  take  a  specimen  in  cases  of  fibro- 
mata   mvomata,  Ivmphadenomata,  etcetera. 

One  of  the  limitations  of  gastroscop>  at  present  is  the  limited  value 
to  be  placed  ttpon  negative  results.  Any  lesion,  if  it  exist  in  the  explor- 
able  area  can  be  seen  and.  if  advisable,  felt,  with  the  probe,  and  its  nature 
determined ;  but  if  no  lesion  be  found  we  cannot  be  certain  that  none 
exists  in  the  unexplorable  area.  However,  with  improvements  m  technic 
this  unexplorable  area  will  be  diminished. 

When  the  gastro-enterologist  shall  have  put  the  instrument  into  fre- 
quent use.  it  is  reasonable  to  expect  that  our  knowledge  of  the  physiology 
and  clinical  pathology  of  the  stomach  will  be  greatly  enlarged. 

In  peptic  ulcer  the  gastroscope  is  of  great  service  both  for  diagnosis 

and  treatment. 

Forcii^n  Bodies.  The  feasibility  of  removing  foreign  bodies  from 
the  stomach  has  been  demonstrated  by  the  author.  Any  foreign  body, 
the  sharp  points  or  edges  of  which  can  be  guarded  by  the  forceps  or  by 
the  end  of  the  tube,  so  as  not  to  lacerate  the  esophagus,  can  be  removed 
from  the  stomach  with  the  aid  of  the  gastroscope. 


CHAPTER    XIX. 
Instruments  for  Gastroscopy. 

The  Gastroscope.  To  examine  the  stomach  requires  frequently  an 
80  cm.  tube,  though  for  many  cases  a  70  cm.  length  is  sufficient.  It  is 
impossible  to  illuminate  a  field  of  view  at  this  distance  by  any  form  of 
light  projected  in  through  the  proximal  end,  for  while  the  loss  of  light  is 
not,  with  parallel  rays  and  a  polisVied  interior,  as  the  square  of  the  dis- 
tance, there  is  too  great  a  loss  for  practical  work.  Kirstein's  light,  though 
excellent  for  other  purposes,  is  useless  for  this  great  length.  In  addition 
to  the  loss  by  distance,  there  is  the  loss  from  slight  springing  of  the  tube 
and  from  bubbles  in  its  lumen.  These,  while  not  interfering  greatly  with 
vision,  do  cut  off  much  of  the  light  projected  in. 

With  the  gastroscope  shown  (Fig.  17),  the  length  of  tube  is  immate- 
rial. Tile  view  is  as  good  at  the  end  of  an  80  cm.  tube  as  that  of  a  45  cm. 
esophagoscope  of  the  same  diameter. 

The  construction  of  the  instrument  is  the  same  as  the  bronchoscopes 
and  esophagoscopes  devised  by  the  author. 

In  the  wall  of  the  gastroscope,  as  in  the  esophagoscope,  there  are 
made  two  small  auxiliary  tubes  or  canals.  Both  of  these  canals  open  into 
the  main  tube  close  to  the  distal  end.  One  canal  ends  near  the  handle  in  a 
tip  for  the  attachment  of  rubber  tubing  connected  with  the  aspirating 
apparatus.  This  keeps  the  field  clear  of  all  fluids,  and  prevents  smearing 
of  the  lamp.  Large  quantities  of  fluids  have  to  be  pumped  out  of  the 
stomach  in  some  cases. 

The  other  canal  is  for  the  light  carrier,  which  is  a  small  removable 
double  conductor  carrying  the  lamp  to  the  distal  end  of  the  instrument 
where  it  sheds  its  light  at  close  range  at  the  point  where  needed,  leaving 
every  object  between  it  and  the  observer's  eye  in  darkness. 

The  diameter  of  the  lumen  of  the  adult  gastroscope  is  10  mm.  Many 
cases  will  permit  a  larger  tube  than  this  and  die  author  uses  frequentlv  a 
tube  whose  outside  dimensions  are  11  mm.  in  one  diameter  bv  14  in  the 
other. 


IXSTRUMEXTS  FOR  GASTROSCOPY.  141 

The  distal  end  of  the  instruniciiL  is  funned  uf  a  thickened  ring  to 
prevent  injury  to  the  tissues. 

The  exterior  of  the  tube  is  not  graduated.  The  depth  is  measured 
with  a  steriHzed  steel  rule  by  noting  the  distance  between  the  proximal 
end  and  the  upper  teeth. 

Thus,  80 — 20=60  centimeters. 

An  obturator  or  mandrin  witli  a  projecting  conical  end  is  fitted  to 


Fig.  72. — The    Clement    Jones   bougie    for    facilitating    the    introduction    of    the 
gastroseope. 

facilitate  the  passing  of  the  inferior  pharyngeal  constrictor,  especially  for 
those  unfamiliar  with  esophageal  work. 

At  the  suggestion  of  Dr.  Clement  Jones,  the  Kny-Scheerer  Co.  have 
made  a  sound  of  90  cm.  in  length  (Fig.  yz)  to  facilitate  the  introduction 
of  the  gastroseope  at  the  hands  of  those  accustomed  to  passing  the  stom- 
ach tube,  but  who  are  unfamiliar  with  the  passing  of  rigid  instruments. 


CHAPTER    XX. 
Technic  of  Gastroscopy. 

Anesthesia.  Cocain  in  a  courageous  patient  is  sufficient  so  far  as 
the  pain  of  examination  is  concerned,  but  it  does  not  stop  the  retching  like 
deep  general  anesthesia.  A  large  dose  of  morphin  given  hypodermati- 
callv  assists.  The  stomach  itself  was  altogether  insensitive  in  the  only 
case  examined  under  local  anesthesia  by  the  author.  Qiloroform  the 
author  considers  dangerous  for  esophagoscopic.  and  especially  for  gastro- 
scopic,  though  not  for  bronchoscopic  work.  Deep  anesthesia  is  absolutely 
necessarv  to  prevent  retching,  which  is  to  be  avoided  while  the  tube  is  in 
the  stomach,  both  because  it  might  be  fraught  with  danger,  and  because  it 
stops  the  examination  by  the  diaphragm  clamping  the  tube  at  the  hiatus. 
Prolonged  deep  anesthesia  is  not  safely  maintainable  with  chloroform. 
Ether,  then,  is  the  choice,  preferably  started  with  nitrous  oxide.  A  little 
chloroform  mav  be  given  from  time  to  time  as  relaxation  is  needed,  espe- 
ciallv  in  bad  ether  subjects.  Dr.  Boyce  has  demonstrated  for  the  author, 
that  chloroform  is  much  preferable  technicall}'  to  ether,  but  this  does  not 
outweigh  against  the  increased  risk. 

Once  the  patient  is  anesthetized,  ether  and  the  occasional  few  drops 
of  cliloroform  are  administered  on  several  layers  of  folded  gauze  laid  over 
the  mouth,  nose,  gag  and  instrument. 

Incidentally  it  may  be  said  that  considerable  quantities  of  the  anes- 
thetic reach  the  stomach ;  whether  it  be  swallowed  or  be  excreted  by  the 
gastric  mucosa,  remains  to  be  demonstrated ;  but  certain  it  is  that  a  strpng 
vapor  is  ejected  from  the  tube  into  the  observer's  eye  during  examination, 
and  this  seems  to  be  the  case  regardless  of  the  n.iethod  of  administration. 

The  preparation  of  the  poticnt.  is,  in  a  general  wa}-,  the  same  as  for 
tracheo-bronchoscopy. 

The  essentials  are  an  empty  gastro-intestinal  canal  and  a  clean  mouth. 
No  food  is  allowed  for  twelve  hours,  black  coffee  and  water  may  be  taken 
within  seven  hours  unless  there  have  been  symptoms  of  pyloric  stenosis, 
in  which  case  eighteen  hours  with  nothing  at  all  per  os  is  essential. 

^^^ashing  out  the  stomach  is  not  a  satisfactory  substitute  for  fasting. 
When  necessarv,  as  in  motor  inadequacy,  it  should  be  done  three  or  four 


TECH.XIC  OF  G.ISTROSCOPy. 


148 


hours  before  the  gastroscopic  examination,  so  that  the  remains  of  food  or 
fluid  will  have  had  time  to  be  absorbed  or  to  pass  on.  The  author  has 
discovered  in  p^astroscopic  investigations  that  after  washing  out  the  stom- 
ach there  are  from  four  to  six  ounces  of  fluid  retained,  pocketed  off  in  the 
folds.  The  autlior  has  never  seen  an  absolutely  empty  human  stomach. 
There  is  always  some  fluid  to  he  drained  or  pumped  from  pockets  and 
valleys  here  and  there. 

Postiirr.  The  author's  earlier  work  was  dune  in  a  ])osture  half  way 
between  the  Trendelenburg  and  the  horizontal,  so  that  fluids  drained  away 
through  the  tube  by  gravity.  But  at  the  suggestion  of  Dr.  E.  S.  Mont- 
gomery he  has  been  using  in  some  instances  the  reverse  of  this:  that  is, 


Fi(i    To. — I'osiiioi:  uf  a>.sUiaiit.s,  nurses,  operator  and  patk'ut  during  the  iulroduc- 
tion  of  the  ga.stroscope. 


with  the  f(X)t  of  the  table  lowered  about  fifteen  inches.  To  do  this,  the 
aspirating  apparatus  has  been  improved  so  that  every  ])ocket  is  pumped 
out  as  soon  as  entered.  This  permits  of  a  comfortable  seat  on  a  stool  for 
the  operator. 

After  the  gastroscope  is  passed  with  the  table  horizontal,  the  plane  of 
the  whole  table  top  is  changed  so  that  the  head  of  the  table  is  about  30  cm. 
higher  than  the  foot.     This  would  be  too  high  for  starting. 

The  jxisition  of  the  patient,  operating  table,  operator,  assistants,  anes- 
thetist, nurses  and   apparatus  during  the  starting  of  the  gastroscope  is- 
shown  in  Fig.  j^.     The   diagram    (Fig.   41 )    shows  the  positions   more 


144  PASSING  THE  GASTROSCOPE. 

accuratelv.  These  positions  are  absolutely  essential,  because  of  the  length 
of  the  instruments.     Otherwise  everything  will  be  in  chaos. 

Passing  the  Esophagoscope  or  the  Gastroscope.  The  first  essential 
is  gentleness.  If  the  tube  does  not  pass  readily  it  is  either  not  in  the  right 
place  or  not  rightly  directed.  The  tube  should  be  well  lubricated  with 
vaseline.  The  proximal  end  should  be  held  lightly  between  the  fingers  of 
the  right  hand,  the  handle  directed  horizontally  to  the  right  as  in  Fig.  74, 
which  shows  the  position  as  seen  by  the  operator  looking  down  upon  it. 

The  forefinger  of  the  left  hand  passes  into  the  right  glosso-epiglottic 
fossa,  posteriorly  to  the  lateral  glosso-epiglottic  fold,  posteriorly  to  the 
tense  pharvngo-epiglottic  fold,  and  if  possible  into  the  right  pyriform 
sinus. 

The  tube  then  is  made  to  follow  this  same  route,  while  the  finger 


Fig    74. — Position  ol  the  riglit  liand  during  tlie  introduction  o£  tlie  gastroscope. 
viewed  from  above  by  tlie  operator  loolcing  downward. 

slides  toward  the  median  line  and  lifts  the  tongue  and  anterior  pharyngeal 
tissues  upward  (dorsal  decubitus).  When  the  cricoid  cartilage  can  be 
reached,  which  is  possible  usually  only  in  children,  it  is  better  to  lift  upon 
it  directly  (Fig.  75).  When  impossible,  as  it  is  usually  in  adults,  the 
cartilage  must  be  lifted  indirectly  by  traction  upon  the  tissues  at  the  ex- 
treme point  reachable,  often  the  right  glasso-epiglottic  fossa. 

The  introduction  of  the  gastroscope  is  easy  to  one  accustomed  to  the 
esophagoscope,  and  is  readily  learned  by  any  one.  Personally  the  author 
prefers  itsing  one  index  finger  as  a  guide.  Some  may  prefer  starting  the 
instrument  by  sight,  without  the  obturator  as  in  bronchoscopy ;  others  may 
prefer  threading  the  instrument  over  an  esophageal  bougie  as  suggested 
by  Dr.  Clement  R.  Jones.  Whichever  of  these  methods  be  used,  as  soon 
as  the  introitus  is  passed  the  instrument  must  be  guided  by  sight  to  make 
a  safe  procedure.  v 


DUTIES  OP  THE  SE.COND  ASSISTANT. 


14.-) 


The  neck  of  the  patient  is  bent  backward  to  straighten  tiic  cervical 
curvature,  or  rather  to  cause  the  axis  of  llie  oral  cavity  to  approach  paral- 
lelism with  that  of  the  esophagus.  This  also  moves  the  upper  teeth  as 
nuich  as  possible  out  of  the  wav  of  the  tube. 

In  bending  tlie  neck  the  angle  should  be  as  much  as  possible  at  the 
upper  cervical  vertebrae  so  as  to  straighten  the  oro-pharyngeal  angle  as 
much  as  feasible,  while  keeping  the  pharyngeal  axis  as  straight  as  it  can 
be  kept.  After  the  tube  is  started  the  head  may  have  to  be  raised  (supine 
patient)  slightly  to  prevent  tracheal  compression. 

Dr.  Bovce  has  develo|)ed  the  details  of  holding  the  head  to  a  degree 


Fig.  To. — Diagramalio  positiou  of  the  left  band  in  starting  the  esophagoscope  or 
gasti'oscope. 

of  perfection  that  makes  all  endoscopy  per  os  easy.  It  is  more  difficult  to 
teach  an  assistant  how  to  hold  the  head  than  to  teach  him  endoscopy.  Tlie 
following  is  a  description  of  the  correct  position. 


DUTIES  OF  THE  SECOND  ASSISTANT  IN  ENDOSCOPY 

PER  OS. 

By  Dr.  John  W.  Boyce. 

In  all  this  work  safety  demands  that  the  mouth,  pharynx,  and  esophagus 
be  brought  into  a  straight  line,  not  by  a  crowbar  like  action  of  the  tube,  but 
by  holding  the  head  steadily  in  extreme  extension  with  the  mouth  widely  open. 
Not  only  does  lateral  pressure  add  to  the  operator's  diflSculty,  but  it  also  en- 
tirely prevents  any  sense  of  what  the  point  of  the  tube  is  touching.  Trial  with 
an  unanesthetized  patient  will  show  that  if  the  head  is  simply  allowed  to  hang 
over  the  edge  of  the  table,  not  only  is  an  unnecessary  strain  thrown  upon  the 
ligaments  of  the  neck,  but  full  extension  is  not  as  well  secured  as  by  proper 
support  of  the  head.  It  is  further  to  be  remembered  that  no  mouth  gag  is 
absolutely  self-retaining  and  a  slight  slip  while  the  tube  is  in  position  may 
have  serious  consequences.  For  this  reason  it  is  best  to  detail  a  second  as- 
sistant to  hold  the  head  and  steady  the  mouth-gag,  impressing  him  with  the 
importance  of  the  matter  and  his  entire  responsibility  therein.  To  carry  him 
out  of  the  operator's  way  it  is  necessary  that  he  shall  hold  the  head  at  arm's 


146 


DUTIES  OF  THE  SECOXD  ASSIST AXT. 


length  and  to  hold  it  in  this  position  steadilj'  for  fifteen  or  twenty  minntes  a 
support  is  necessary.  The  weight  of  the  head  is  so  little  that  the  matter  seems 
easy,  but  if  the  assistant's  arms  are  unsupported,  about  the  time  the  most 
critical  point  of  the  examination  or  operation  is  reached  his  muscles  will  be 
trembling.  Nor  is  it  possible  to  rest  him  by  any  shift  of  position  after  the 
tube  is  started,  .\fter  many  unsuccessful  trials,  it  has  been  found  that  the 
best  position  is  as  shown  in  Fig.  76.  The  patient  is  drawn  forward  until  the 
tops  of  his  shoulders  clear  the  table  by  from  four  to  six  inches,  and  the  mouth- 


^•V^ 


Fig.  70. — Position  of  sucond  assistant  and  patient  for  endoscopy  per  os. 
caps  and  cover.*  arc  omitted  better  to  show  the  positions. 


Gowns. 


gag  is  inserted  on  the  left  side.  The  assistant  is  placed  on  the  right  side  of 
the  patient's  head  on  a  stool  of  appropriate  height,  as  though  on  a  side  saddle; 
his  right  leg  beneath  him  in  the  kneeling  position,  his  left  foot  supported  on  a 
stool  26  inches  lower  than  the  top  of  the  table;  his  right  forearm  is  passed 
beneath  the  patient's  neck,  supporting  it;  his  right  hand  grasps  the  mouth-gag 
drawing  it  strongly  backward.  His  left  hand  rests  on  the  left  knee,  grasps  the 
head  strongly  at  or  in  front  of  the  bregma,  bending  it  backward  and  exerting 
a  certain  degree  of  upward  pressure.  The  exact  proportion  of  backward  and 
upward  pressure   cannot  be  described,  but   is  readily  appreciated   on   trial,  es- 


i'assim;  the  cisTROscorn.  i  it 

pecially   it"   the   assistant   lias   actually   oxperienccd    the   difference   in    sensation 
when   the  head  hangs   free  and   when  it   is  properly  supported   in   extreme   ex- 


After  the  introitus  is  passed,  the  obturator  is  rcmovcrl,  the  cord  is 
attached  to  the  light  carrier  by  the  bayonet  fitting,  which  by  rotation  is 
used  as  a  switch  to  turn  on  and  oft"  the  current,  the  rheostat  on  the  battery 
having  been  previously  reguhited  to  full  illumination  when  the  instruments 
were  ])repared.  Turning  the  ba\-onet  fitting  now  lights  up  the  instrument 
and  the  passing  is  under  the  guidance  of  the  eye.  the  sense  of  touch  onl_\- 
being  used  to  note  resistance,  which  if  felt,  means  something  to  be  over- 
come bv  skill,  not  force.  Once  started,  the  passage  of  the  instrument 
down  the  esophagus  is  easy  if  three  important  points  are  watched: 

1.  The  instrument  must  have  been  well  greased  before  starting. 

2.  The  tube  must  be  guided  by  the  eye  so  as  to  follow  the  esophgeal 
lumen  by  sight. 

3.  The  pinching  of  the  tube  by  the  teeth  must  be  avoided  so  that 
the  tube  will  be  free  to  move  as  needed  to  follow  the  axis  of  the  esophageal 
lumen  as  it  is  seen  to  open  up  ahead. 


Ik;.   77. — Diagram   showing  occlusion   of   the   trachci   hy    faulty   dirnlion   of   the 
gastroscope  (or  esopbagoscope). 

4.  The  holding  of  tlie  head  must  be  exactly  as  just  described  by  Dr. 
Boyce. 

After  passing  the  introitiis  care  must  be  taken  to  raise  the  head  of  the 
patient  slightly  to  prevent  the  tube  pressing  on  the  trachea  (Fig.  yj). 
This  is  readily  noticed  if  the  passing  is  done  by  sight. 

In  finding  the  lumen  the  normal  respiratory  movements  are  of  great 
assistance.  The  way  often  seems  to  be  completely  blocked  ahead  by  what 
seems  to  be  the  esophageal  wall,  but  with  the  next  inspiration  a  lumen  ap- 
pears in  one  or  other  quadrant  of  the  tube,  a  few  bubbles  are  seen,  and  the 
tube  is  readily  glided  along. 

The  introitus  passed,  onlv  two  points  will  give  any  trouble.  The  first 
is  at  the  hiatus  diaphragmatis.  the  second  the  bend  of  the  abdominal 
esophagus  to  the  left.  The  hiatus  is  passed  by  placing  the  long  axis  of 
the  elliptic  cross  section  of  the  tube  from  the  right  posteriorly  forw-ard 
toward  the  left  anteriorly.  This  is  easily  done  by  placing  the  handle  of 
the  gastroscope  in  the  direction  of  the  visual  axis  of  the  ]3atient,  if  he  were 


148 


PASSING  THE  GASTROSCOPE. 


looking  forward  (if  erect)  to  the  left.  The  axis  of  the  hiatus  is  shown  in 
Figure  59. 

Full  relaxation  assists  passing  both  the  hiatal  narrowing  and  the 
abdominal  esophageal  bend. 

The  abdominal  esophagus  is  readily  passed  if  the  head  and  neck  of 
the  patient  are  moved  to  the  right  (Fig.  78)  and  the  lumen  is  carefully 
watched  and  followed.  The  difficulty  met  here  is  very  nutch  like  the  fold- 
ing over  of  the  trousers  when  the  foot  is  not  inserted  in  the  right  direction. 

If  any  serious  difficulty  is  experienced  in  passing  the  hiatus,  it  will 
be  found,  usually,  that  the  patient  has  come  partially  out.     Upon  deepen- 


FlG.  78. — Schema.  Head  and  neck  moved  to  right  to  reach  left  limit  of  the  ex- 
plorable  area ;  also,  during  introduction,  to  pass  through  the  hiatus  and  abdominal 
esophagus. 


ing  the  anesthesia  the  gastroscope  will  glide  easily  through  the  hiatal 
esophagus  into  the  subphrenic  portion  if  the  lumen  be  watched  for 
through  the  tube  and  follow^ed.  This  involves  a  lateral  drag.  After  the 
distal  end  of  the  tube  is  in  the  stomach,  the  exploration  is  easily  accom- 
plished if  a  systematic  plan  be  followed.  From  one  to  six  square  centi- 
meters are  visible  at  one  time,  so  that  a  systematic  plan  of  tube  travel  has 
to  be  followed  to  be  reasonably  certain  of  examining  all  portions  of  the 
ventricular  mucosa. 


TECHXIC  OF  G.ISTKUSCOI'Y. 


14!) 


There  are  two  plans  of  exploration,  both  of  which  should  be  carried 
out.  First  the  tjastroscope  should  be  jiassed  down  carefully  and  gently  to 
the  greater  curvature,  inspecting  the  anterior  and  j)ostcrior  walls.  At 
times  these  walls  do  not  seem  to  be  fully  collapsed  ahead  of  the  tube  and 
one  will  have  to  be  examined  first,  then  the  other.  Then  the  tul)e  is  with- 
drawn, inclined  slightly  laterally  in  the  same  iilane.  then  pushed  gently 
downward  again  in  a  new  series  of  folds.  This  is  repeated  until  the  ex- 
treme pyloric  limit  is  reached.  To  reach  this  limit  the  head  and  neck  of 
the  patient  are  moved  to  the  left  (Fig.  79)  with  the  tube  below  the  cardia. 

After  the  whole  possible  range  has  been  covered  in  this  way.  we  pro- 


FiG.  79. — Schema.     IK-aJ  uuJ  ueck  moved  to  left  to  reach  right  limit  of  the  ex- 
plorable  area. 


ceed  to  the  second  plan.  The  tube  is  passed  down  until  the  extremity 
touches  the  wall  of  the  greater  curvature  in  the  extreme  left  of  the  pos- 
sible field.  Then  the  tube  is  moved  slowly  along  the  greater  curvature, 
but  not  in  too  close  contact  tiierewith.  until  the  extreme  right  is  reached. 
Withdrawing  the  tube  a  centimeter  or  two.  the  field  is  slowly  swept  again 
in  the  same  plane,  but  at  a  higher  level,  and  so  on  upward  to  the  cardia. 
Next  the  deft  fingers  of  one  skilled  in  abdominal  palpitation  are  called 
upon  to  manipulate  the  unexplored  portions  over  in  front  of  the  tube. 
This  is  sometimes  better  accomplished  by  turning  the  patient  on  his  side, 


150  TECHXIC  OF  GJSTKOSCOPY. 

first  on  line  then  on  the  otlier.  DurinL;-  all  these  manipulations  the  tube 
must  be  \\  itlvlrawn  witiiin  the  esophas^us.  When  the  stomaeh  is  in  its 
new  position  the  gastroscope  is  again  pushed  downward  and  the  newly 
available  surfaces  are  explored.  Should  retelling  supervene  while  the 
gfastroscope  is  in  the  esophagus,  no  harm  will  result.  Init  when  the  tulie  is  in 
the  stomach,  retching  is  the  signal  for  immediate  withdrawal  of  the  gas- 
troscope until  the  distal  end  of  the  tube  is  above  the  diaphragm.  No 
harm  has  been  done  in  a  number  of  the  author's  cases  where  retching  has 
occurred  with  the  tubal  extremity  in  the  stomach,  vet  it  is  to  be  regarded 
as  dangerous  in  diseased  conditions  at  least,  and  to  be  avoided  in  all  cases. 

The  vertical  diameter  of  the  stomach  is  easilv  determined  by  meas- 
iirement.  The  depth  from  the  teeth  to  the  cardia  is  taken,  then  the  gas- 
troscope is  pushed  on  down  until  the  greater  curvature  is  encountered  and 
the  distance  from  the  teeth  again  is  taken.  The  diiTerence  between  this 
and  the  first  measurement  gives  the  vertical  diameter  of  the  stomach  at 
this  point.  Care  must  be  used  that  the  measurements  are  not  rendered 
inaccurate  by  pushing  the  greater  curvature  downward,  which  is  exceed- 
ingly easy  to  do  without  knowing  it,  if  the  sense  of  touch  is  relied  upon 
to  determine  when  the  lower  wall  is  reached.  If  the  downward  progress 
of  the  gastroscope  is  watched  through  the  upjier  orifice,  it  is  easy  to  see 
when  the  wall  at  the  greater  curvature  is  touched.  Having  taken  our 
measurements,  we  then  place  the  obturator  externally  parallel  to  the  tube 
within  and  indicate  to  the  abdominal  manipulator  the  exact  position  of  the 
lower  end  of  the  tube  which  he  can  then  mark  on  the  skin,  giving  thus 
with  absolute  certainty  the  exact  location  of  the  greater  curvature  of  the 
empt}-  stomach  at  that  point.  Care  must  be  taken  of  course  to  re-steril- 
ize the  obturator  should  it  touch  anything  unclean. 

The  smallest  vertical  diameter  found  by  the  author  in  any  adult  was 
4  cm.  (I'j  inches)  and  the  greatest  36  cm.  (14  inches). 

There  is  a  tendency  for  the  gastric  walls  to  be  dragged  along  with 
the  tube  when  the  tube  is  moved,  so  that  we  shall  not  get  a  full  new  area 
unless  care  be  taken.  Withdrawal  for  a  few  cm.,  followed  by  re-insertion, 
allows  the  walls  to  regain  their  average  place. 

The  time  required  to  examine  the  entire  explorable  area  is  about 
thirty  minutes,  if  there  are  no  interruptions. 


CHAPTER    XXI. 
Area  of  the  Stomach  Lxplorable  by  Gastroscopy. 

Tt  ,.av  be  acccpte.l  as  an  axio.n  tbat  the  more  horizontal  the  stomachal 
posit':S;e  less  J,l  he  the  e.plorable  area.     Thus  ^-roptotu.  v.n,c^ 
Ld  infantile-form  stomachs  afford  the  greatest  range.     The  reason  tor 
2t  ;:  atonce  apparent  when  we  consider  that  the  lateral  range  ot  mot.on 
is  that  of  the  hiatus  esophageus. 

The  lateral  distance  to  which  this  hiatus  can  be  slutted  ^'"'^;- 
the  individual  being  greatest  in  feeble,  elderly,  emacated  patents,  and 
vM  h^S  h  of  an^s^esia,  being  greatest  in  profound  chloroform  a,je. 
esia  The  antero-posterior  mobility  of  the  hiatus  ,s  of  h  tie  use  ( ex  ep^ 
arS;ili^ng  the  pLing  of  the  tube  at  this  point)  for  the  surroun.hng 
"scera  crowd  the  stomach  walls  in  ahead  of  the  tube,  and  usuallv  both 
anterior  and  posterior  walls  are  visible  at  one  tmie. 

The  pivotal  point  of  rocking  of  the  gastroscope  .s  ---\'--  ;  ^ 
thorax,  not,  as  might  be  supposed,  either  at  the  upper  thoracK  ap.rtu.e 
or  at  the  hiatus  esophageus.      (  Schema,  b  ig.  80. ) 

The  full  range  of  the  upper  thoracic  aperture  ,s  --1^"^  5;^'*^\'  ; 
the  whole  head  and  neck  laterally,  as  well  as,  n.  some  cases,  shghtu  ante 

^°"^r':;dio4if"(S^tj'bl  Dr.  .oggs.  taken  in  the  li.ng  under 
ethe7  how^^  rang!  ofmotion  of  the  gastroscope  in  th,s  particular  ^ase 
of  gastroptosis.  which  was  not  a  very  good  one  for  den.onstrat.on  as  re- 
laxation was  not  complete  and  the  diaphragm  hampered  movement. 
'^ol^Lrilv  there  is  no  diffictdtym  making  the  ^^^^^^  -- 
toward  the  ri-ht  and  the  left  anterior  superior  spnie  ol  the  il  um.        He 


no  force  was  used,  and  it  was  not  a  case  of  ecta.-,ii.. 

rFicr  8^)  shows  the  position  of  the  pylons  m  this  case. 

^     'if  ;i  e     iaphragn'   were  rigid,  gastroscopy  would  be  very  much  ban. 

pered      I'ut  ,t  has.  when  the  patient  is  fully  relaxed  under  anesthesia,  a 


152 


EXPLORABLE  AREA. 


range  of  flexibility  that  may  be  averaged  roughly  at  a  5x15  centimeter 
ellipse,  the  long  axis  being  laterally,  and  a  very  slight  antero-posterior 
rocking  will  bring  either  the  anterior  or  posterior  wall  into  view  alone. 

In  one  gastroptotic  stomach  the  author  succeeded  in  exploring  about 
the  entire  mucosal  area.  In  one  instance,  a  horizontal  stomach,  not  more 
than  one-third  of  the  stomach  could  be  explored. 


Fig.  so. — Schema.     Showing  extreme   right  aud   left   positions. 


In  the  foregoing  remarks  reference  is  had  only  to  cases  in  which  the 
esophagus  is  normal.  Anomaly  or  organic  disease  of  the  esophagus  may 
render  esophagoscopy  and  gastroscopy  difficult  or  impossible. 


GASTKOSCOPy. 


l.>i 


Fig.  si. — Radiograph  of  gostro-scope  in  two  ditFerent  positions,  in  a  case  of  gas- 
ti'optosis,  the  patient  under  etiier.  Sbadow  of  coin  locates  tlie  umbilicus.  ( Radi- 
graph  by  Dr.  Russell  H.  Boggs. ) 


G.-^STROSCOPY. 


n 


rv  <^^y:^.-'iyfe*yv^' >■>'->>  ■ 


V'.  .aavVaC 


Flo.  S2. — Kadiograph  of  gasl  roscope  in  position  in  tin'  living  patient.  Tiilje 
mouth  iu  tlifi  pyloris  (gastroptosis).  .Shadow  of  coin  louatos  the  umbilicus.  (Radio- 
graph by  Dr.  Russel!  H.  Boggs.) 


CHAPTER    XXII. 
Difficulties,  Dangers  and  Contra-Indications. 

Difficulties.  When  it  is  said  that  gastroscopy  is  easy,  it  is  not  meant 
tlnat  no  training  is  necessary.  One  does  not  learn  ophtiialmoscopy  in  a 
day.  Yet  so  far  as  seeing  the  tissnes  is  concerned,  gastroscopy  is  the 
easier. 

There  are  two  classes  of  dil^ficulties.  They  are  toth  slight  and  easily 
surmounted.  One  class  concerns  manipulation,  including  introduction 
and  exploration,  and  the  other  class  concerns  the  eye,  which  consists  in 
comprehending  the  picture. 

Those  physicians  who  have  looke.l  through  the  instrument  at  tUe 
stomach  mucosa  without  any  previous  training  at  tube  work,  or  at  oph- 
thalmoscopv  or  microscopy,  have  been  able  to  see  clearly.  Some  of  these 
same  men  have  said  that  they  cannot  tell,  on  looking  into  an  ear.  what  is 
drum  membrane  and  what  is  canal. 

Naturally,  those  accustomed,  like  the  laryngo-rhinologist.  to  viewing 

deep-seated  mucoss  with  one  eye,  while  relaxing  the  accommodation  of 

the  other  eye,  and  ignoring  its  image  will  be  enabled  to  see  at  a  glance. 

His  experience  in  intubation  and  in  esophageal  work  will  also  make 

him  facile  at  passing  the  instrument. 

By  this  It  is  not  meant  that  gastroscopy  should  be  done  by  the  laryn- 
gologist.  On  the  contrary,  it  is  the  province  of  the  gastro-enterologist, 
The  physician  and  the  surgeon.  None  of  these  will  have  the  slightest 
difficulty  in  acquiring  the  necessary  technic,  and  manual  dexterity. 

Lordosis,  Potts  disease  and  other  morbid  conditions  of  the  vertebra: 
mav  make  gastroscopy-  impossible. 

'  Daiii;a-s.     In  careful   hands  there  is  no   danger  other  than   that  of 
ether  anesthesia. 

In  general,  it  mav  be  stated  that  the  stomach  is  a  very  much  less  sensi- 
tive organ  than  the  esophagus  ;  not  .mly  less  sensitive  in  the  strict  meaning 
of  the  Sensation,  but  in  the  matter  of  efferent  impulses  for  the  production 


loG  DANGERS  OF  GASTROSCOPY. 

of  reflexes,  and  of  congestion  and  inflaniinatory  reactions  to  local  irrita- 
tions. 

As  the  real  question  of  importance  is  as  to  shock  incident  to  the 
passing  of  a  rigid  instrument  through  the  entire  length  of  the  esophagus, 
(which,  a  priori,  would  seem  the  only  question  of  importance  as  the  stom- 
ach is  quite  insensitive)  a  number  of  sphygmomanometric  observations 
upon  the  author's  cases  were  made  by  Drs.  Boyce,  Barach  and  Upham. 
Tbe  analysis  of  these  observations  was  published  in  the  jMedical  Record, 
from  which  the  following  is  quoted : 

"Gastroscopy  is  apt  to  be  done  under  very  shallow  anesthesia,  and  the  pres- 
sure curve  is  particularly  likely  to  be  distorted  by  accidental  circumstances, 
but  in  the  four  cases  observed,  the  readings  were  fairly  imiform,  and  it  seemed 
safe  to  say  that  there  is  ordinarily  no  appreciable  disturbance  of  the  circula- 
tion, but  that  in  an  occasional  case  the  characteristic  esophageal  fall  will  occur 
from  the  passage  of  a  rigid  instrument  of  this  length.  In  these  cases,  how- 
ever, the  pressure  does  not  remain  at  the  low  point,  but  starts  to  rise  at  once 
and  reaches  the  original  level  while  gastroscopic  search  is  in  progress." 

Gastroscopy  certainly  is  not  as  dangerous  as  passing  a  sound  or  tube, 
for  all  diseased  spots  are  seen  and  pressure  upon  them  avoided.  Thus  in 
malignant  disease  of  the  cervical  esophagus,  the  natural  constriction  at  the 
introitus  is  increased,  and  carelessness  might  force  a  stomach  tube 
through,  but  with  the  rigid  gastroscope  passed  by  sight  the  growth  at  once 
is  discovered.  As  stated,  the  tube  is  started  with  the  finger,  and  a  pre- 
vious laryngoscopic  examination  is  relied  upon  to  exclude  disease  of  the 
introitus.  Dysphagia  without  regurgitation  is  usual  in  disease  of  the 
upper  esophagus ;  so  that  in  dysphagia  with  regurgitation  we  may  safely 
conclude  that  the  disease  is  far  enough  within  the  esophagus  to  allow  the 
tube  to  be  started  by  the  sense  of  touch  without  reaching  the  diseased 
tissue. 

Mikulicz  doubted  the  safet}'  of  examining  cases  of  suspected  malig- 
nancy, and  doubtless  he  was  correct,  with  his  instrument  with  its  bend 
which  had  to  be  swung  with  necessarily  imperfect  control,  and  most  im- 
portant of  all  without  seeing  what  the  end  was  doing.  With  a  perfectly 
controllable  straight  instrument  unobscured  and  unweighted  with  a  tele- 
scopic optic  apparatus,  the  touch  is  gentle,  certain  and  under  full  control. 

Suspicious  spots  can  be  seen  and  pressure  upon  them  avoided.  Dis- 
v-'ase  of  the  abdominal  esophagus,  which  makes  a  more  or  less  sharp  turn, 
(relative  to  the  advancing  tube)  would  be  particularly  dangerous  with  an 
instrument  passed  blindlv. 

As  to  the  danger  of  taknig  a  specimen,  the  author  has  done  so  in  a 
number  of  cases  without  any  ill  result.  They  were  all  cases  associated 
with  fungation.     It  is  wise,  probably,  not  to  remove  a  specimen  from  the 


coNTR.i-i\Dic.rno.\'s  to  GASTROSCOI'V.  1">7 

edge  of  a.:y  flat  ulceration,  as  there  nni;-ht  lie  some  risk  of  perforation,  or 
possiblv  of  hemorrhage. 

The  foregoing  statement  of  dangers  is  based  upon  the  utmost  gentle- 
ness of  manipulation  under  the  relaxation  of  deep  anesthesia;  the  passage 
of  the  gastroscope  bv  sight :  the  withdrawal  of  it  within  the  esophagus, 
should  retching  supervene:  and  upon  the  strict  ,.bservance  of  all  the  mmor 
details  already  alluded  to. 

Confra-indicahoiis.  \Miile.  as  stated,  there  is  practically  no  danger, 
there  are  certain  cases  where  gastroscopy  is  not  advisable.  In  the  pro- 
found cachexia  of  the  last  stages  of  malignancy :  in  the  profound  anemia 
of  inanition  from  known  or  unknown  cause;  cardiac,  pericardiac  or  major 
vascular  lesions ;  general  or  local,  acute  or  chronic  conditions  associated 
with  either  dyspnoea  or  dropsical  effusions ;  the  late  stages  of  organic  dis- 
eases, as  cirrhosis  of  the  liver,  nephritis,  etc. 

It  will  be  noted  that  all  foregoing  conditions  are  really  contra-mdi- 

cations  to  anesthesia. 

While  it  is  bv  no  means  certain  that  even  in  these  cases  there  is  any 

danger  other  than  that  of  anesthesia,  it  is  prudent  to  be  particularly  care- 
.  iul.'m  the  earlv  development  of  gastroscopy,  not  to  risk  a  death  that, 
"  rightlv  or  wrongly,  would  be  attributed  to  the  procedure  and  not  to  the 

anesthetic  or  the  concomitant  aneurysm  or  other  lesion,  thus  attaching  a 

stigma  of  danger  to  a  safe  and  useful  procedure. 


CHAPTER    XXIII. 
Gastroscopic  Appearances. 

In  describing  and  illustrating;  what  he  has  seen,  the  author  wishes  to 
])oint  out  that  these  may  not  be  usual  or  averag-e  appearances.  They  are 
only  descriptive  and  illustrative  of  these  particular  cases.  Not  until  at 
least  a  thousand  cases  have  been  examined  can  any  ono  say  what  is  the 
average  or  usual  appearance  of  normal  and  pathologic  conditions.  Nor, 
until  then,  can  any  one  properly  classify  the  latter.  This  opens  up  an 
enormous  field  for  research. 

There  are  many  difficulties  in  the  wav  of  reproducing  the  gastro- 
scopic views.  These  difficulties  have  been  surmounted  so  far  as  possible 
in  the  accompanying  color  drawings  which  were  made  by  the  author  from 
memory  after  the  examinations.  They  are  only  a  few  of  thousands  of 
pictures. 

Normal.  The  folds  of  the  stomach  form  an  endless  variety  of  pic- 
tures in  front  of  the  gastroscope.  A  hundred  or  more  difTerent  views  are 
presented  at  a  single  examination.  Not  that  the  folds  themselves  vary  so 
much,  but  the  manner  in  which  they  are  presented  to  the  tube  varies. 

T'here  is  one  horseshoe-shaped  form  (Figs.  4,  16  and  18,  Plates  IV 
and  V)  that  is  often  seen,  especially  near  the  cardia.  It  seems  to  come 
most  often  from  the  lesser  curvature,  and  to  be  formed  by  the  tube  mouth 
encountering  a  fold  at  nearly  a  right  angle  to  the  side  of  the  fold.  In 
some  instances  it  may  be  formed  at  the  branching  of  a  fold. 

When  the  tube  mouth  enters  the  cardia  the  folds  seem  to  extend  down- 
ward away  from  the  tube  and  parallel  with  its  axis,  and  the  tube  enters 
upon  a  half-open  tunnel,  the  walls  of  which  are  formed  by  longitudinally 
arranged  ridges  separated  by  narrow  and  deep  valleys.  The  sense  of 
depth  of  the  tunnel  is  difiicult  to  portray.  Proceeding  on  down  this  tun- 
nel the  ridges  show  a  lateral  trend  and  we  suddenly  end  with  a  blank, 
sometiines  mottled  surface,  rather  flat,  sometimes  slightly  ridged.  It  flat- 
tens and  blanches  as  we  proceed  downward,  for  although  we  have  en- 
countered the  wall  of  the  greater  curvature  of  the  stomach,  we  do  not 


^forF.^[l:^'Ts  or  the  stomach.  i')'.t 

realize  it  at  once  by  the  touch  as  we  pu^li  it  on  (lnwnw.'ird  fur  len  or  more 
centimeters  before  resistance  is  felt,  if  the  patient  he  fully  anesthetized. 
If  the  jiatient  comes  out  partially  and  bevjins  retchins;'  resistance  is  at  once 
felt,  but  less  than  misiht  be  expected. 

\\'hen  the  tul)e  i.s  withdrawn  the  di^k  of  tlattened  stomach  wall  fol- 
lows the  tube  mouth  in  close  contact  to  a  position  sometimes  higher  than 
where  it  was  encountered. 

Landmarks,  among'  these  folds,  in  size  or  direction,  will  be  discciv- 
ered,  probably,  but  as  yet  orientation  is  difficult  except  by  the  general 
sense  of  direction  and  distance  from  the  cardia.  This  is  difficult  to  esti- 
mate because  of  the  dragging  along  of  the  walls  by  the  tube. 

In  addition  to  the  change  iri  form  of  the  folds  by  the  pressure  of  the 
tube,  variations  are  caused  by  the  various  movements. 

The  iiwvciiiciits  of  the  stomach  are  constant.  The\'  may  be  classified 
into  respiratory,  pulsatory,  anti-peristaltic  and  peristaltic.  llie  latter 
class  possibly  includes  different  motions  which  further  work  will  analyze. 
Of  the  anti-]ieristaltic  movements  there  are  two  kinds,  the  duodenal  vari- 
ety Ijeing  limited  to  the  pyloric  end  and  the  vomitory  to  the  fundal  half. 
Other  movements  of  the  stomach  resulting  from,  apparently,  the  activity 
of  its  own  muscular  fibres,  are  frequently  seen,  and  may  be  classed  as 
peristaltic,  but  may  be  due  to  the  communicated  movements  of  adjacent 
intestines. 

Tlie  respiratory  movements  in  the  strmiach  are  not  so  marked  as 
those  in  the  esophagus.  They  seem  to  produce  alternately  negative  and 
positive  pressures.  They  are  sufficient  to  cause  an  in-and-out  flow  of  air, 
the  outflow  being  strongly  saturated  with  the  vapor  of  the  anesthetic  which 
is  present  in  considerable  quantity  in  the  gastric  secretions. 

The  pulsatory  movements  are  transmitted  from  the  heart  and  to  a 
great  extent  from  the  descending  aorta.  The  impulses  are  not  so  strong 
as  those  in  the  esophagus  where  the  aorta  is  crossed. 

The  p^■lcric  third  is  the  most  unstable  portion  of  the  stomach.  In 
one  instance  the  pylorus  was  surrounded  by  a  rosette  of  annular  folds. 
In  another  case  the  folds  were  seen  to  be  larger  as  the  pylorus  was  ap- 
proached. These  folds  would  cur\-e  in  ahead  of  the  tube,  tlien  be  pushed 
aside  by  the  advancing  tube  mouth.  Finally  cue  large  fold  was  moved 
aside  and  a  slit  something  like  Fig.  25  came  into  view.  Almost  imme- 
diately it  resolved  itself  into  a  rounded  opening  which  receded  into  a  cup- 
like depression  followed  by  the  wrmkling  into  the  tube  of  numerous  small 
folds  as  shown  in  Fig.  26,  accompanied  by  the  ocuding  of  a  dram  or  two 
of  dark  cloudy  olive-colored  fluid.  This  evidently  was  an  anti-peristaltic 
movement,  and  it  immediately  preceded  retching. 

This  was  at  the  apex  of  the  interior  of  a  hollow   cone,  the  walls  of 


IHO  GASTROSCOPIC  APPEARANCES. 

which  the  tube  had  followed.  The  question  arose  in  the  author's  niinu 
whether  this  was  the  pylorus,  or  the  constriction  of  an  hour-glass  con- 
traction, or  the  kink  of  a  gastroptotic  stomach.  Either  of  the  latter  might 
show  a  narrowed  opening  lying  at  the  apex  of  the  interior  of  a  hollow 
cone,  with  a  reverse  flow  of  fluid  exuding,  and  an  hour-glass  contraction 
might  show  the  depth  beyond ;  but  the  question  was  decided  when  the 
small,  annular  duodenal  folds  beyond  were  seen,  and  no  doubt  remained 
when  these  folds  wrinkled  up,  came  toward  the  tube  and  filled  the  opening. 

There  seemed  to  be  a  degree  of  rh\1;hm  in  the  movements  of  the  py- 
loric end  of  the  stomach  in  one  case,  but  the  author  could  not  be  certain. 
It  was  a  much  slower  rhythm  than  that  of  the  heart,  the  movements  being 
a  minute  or  two  apart.  Whether  the  presence  of  the  tube  was  a  factor  in 
their  production  or  not,  could  not  be  determined. 

The  line  of  demarcation  between  the  esophageal  and  the  gastric  mu- 
cosa is  sometimes  one  of  strongly  constrasting  color.  The  gastric  mucosa 
varies  more  in  tint  than  does  the  esophagus,  probably  on  account  of  its 
greater  vascularity.  It  is  at  times  a  deep  crimson  and  then  the  contrast 
with  the  pale  pink  mucosa  of  the  esophagus  is  marked.  The  contrast  is 
represented  by  writers  on  esophagoscopy  as  much  greater  than  it  really  is, 
because  the  writers  have  never  seen  it  except  by  endoscopic  tubes  that  use 
reflected  light  projected  down  into  the  tube  from  without.  This  brings 
out  the  esophageal  margin  in  pale  pink,  while  the  insufficiently  illuminated 
depths  of  the  stomach  are  all  in  dark  shadow  if  indeed  they  can  be  seen  at 
all,  and  thus  the  true  color  of  the  gastric  mucosa  has  never  been  seen 
properly  illuminated. 

While  in  some  cases  it  is  a  very  dark,  deep  crimson,  it  is  quite  often 
verv  pale  pink.  In  one  case,  the  color  of  the  stomach  about  an  hour  after 
taking  a  glass  of  milk  was  crimson  (Fig.  i6,  Plate  III),  due  to  the  en- 
gorge;nent  of  active  function  from  the  presence  of  food.  Half  hour  after 
vomiting  the  milk  the  mucosa  was  very  i^ale. 

In  another  case,  the  mucosa  was  this  same  color  four  hours  after  tak- 
ing chicken  soup,  but  as  whiskey  had  been  taken  about  one  hour  before 
this  may  have  uifluenced  the  vascularity  and  consequently  the  color. 
There  was  carcinomatous  pyloric  stenosis,  also,  in  this  case,  with  conse- 
quent feeble  motility. 

In  many  cases  of  foreign  body  in  the  esophagus  the  author  has  used 
a  gastroscope  instead  of  an  esophagoscope,  and  after  removing  the  foreign 
body  has  taken  a  look  at  the  gastric  mucosa  by  passing  the  cardia.  These 
were  presumably  healthy  stomachs,  and  from  these  experiences,  as  well  as 
the  views  obtained  in  cases  where  only  cardiospasm  and  csophagismus 
were  found,  he  has  come  to  the  conclusion  that  \\hen  the  stomach  is  empty 
its  nnicosa  varies  from  pale  red  to  pale  pink,     llie  co'or  seems  deeper  in 


GJSTROSCOPIC  APPEARANCES.  161 

ether  anesthesias  than  wlun  chloroform  is  used,  prohably  due  to  the 
greater  engorgement  of  tlie  stomach  vessels.  Possibly  it  may  be  the  ether 
present  in  the  stomach.  It  was  much  less  deeply  colored  than  in  the  two 
cases  examined  after  eating  food. 

The  gastric  mucosa  as  seen  through  the  gastroscope  presents  a  moist 
appearance,  but  it  has  a  more  velvety,  less  glistening,  and  less  transparent 
look,  than  the  upper  mucosre. 

The  visibilitv  of  the  minute  arterial  twigs  is  a  matter  which  affords 
great  opportunities  for  investigation. 

Vessels  are  not  usually  visible  through  the  gastroscope  in  the  normal 
gastric  mucosa  when  the  stomach  is  empty,  as  it  usually  is  when  examined 
gastroscopicallv.  In  the  instance  where  the  author  has  seen  vessels,  there 
was  reason  to  believe  that  recent  taking  of  food  or  presence  of  ether  itself 
or  of  ether  intoxication  has  engorged  the  vessels.  Yet  in  some  cases  no 
vessels  were  visible. 

In  one  case  where  the  gastroscope  was  passed  under  cocain  and 
morphin  anesthesia  for  a  foreign  body  in  the  esophagus,  after  removing 
the  foreign  body,  the  tube  was  passed  on  down  a  few  centimeters  distance 
into  the  stomach  and  arterial  twigs  were  noted  in  a  number  of  locations. 
There  were  no  stomach  symptoms  in  this  case,  and  no  secretion  that  lead 
one  to  think  that  a  lesion  might  have  existed. 

Gastritis.  In  one  case  the  mucosa  was  covered  everywhere  with 
thick  pasty  secretions  that  looked  like  an  exudate  and  was  very  difficult  to 
wipe  away.  In  another  case  the  secretion  was  in  patches.  Swallowed 
muco-pus  was  seen  in  several  cases  without  gastritis  lying  free,  not  adher- 
ing :  so  that  tliere  is  no  danger  of  confusing  swallowed  mucus  with  that 
of  the  stomach. 

The  color  of  the  mucosa  was  a  darker  red  in  one  case  than  seemed 
normal,  and  the  mucosa  seemed  thickene<l.  In  only  one  of  these 
cases  were  there  dilated  capillaries  such  as  are  seen  in  chronic  intlamma- 
tion'of  th;  esoi^hagus. 

Many  more  cases  will  have  to  be  examined  before  definite  diagnostic 
appearances  can  be  classified.  This  will  be  but  a  matter  for  repeated  ex- 
aminations, for  the  view  is  as  clear  as  we  get  of  other  mucosae,  chronic 
inflammations  of  wliieh  are  apparer.t  at  a  glance. 

Peptic  Ulcer.  The  gastroscopic  appearance  of  benign  ulcer  was  dif- 
ferent in  each  case.  The  nrst  one  seen  (Fig.  ii.  Plate  IV)  was  a  dirty 
grayish  }'ellow,  (color  in  the  figure  is  too  bright)  not  apparently  iiunched 
out  and  not  infiltrated.  But  at  the  time,  the  author  hesitated  to  touch  an 
ulcer,  and  did  not  mop  the  surface. 

In  the  second  case  (Fig.  28.  Plate  \')  there  was  very  little  secretion, 
and  after  wiijint;  the  surface  it  was  dark  in  color,  did  not  bleed,  and  was 


1(;2  GASTROSCOPIC  APPEARANCES. 

sharpiv  punched  out  in  appearance,  the  edges  being-  sliglitly  infiltrated. 
In  another  case  (Fig.  27,  Plate  \"),  there  was  a  dark  longitudinal  slit  on 
the  crest  of  a  ridge  which  looked  like  an  ulcer,  but  as  it  was  necessary  to 
terminate  the  examination,  it  was  not  possible  to  determine  for  certain. 
There  was  a  cancer  in  the  stomach,  but  this  slit  was  not  part  of  the  growth 
and  was  in  an  otherwise  normal  fold. 

In  another  case(  Fig.  15,  Palate  III)  the  ulcer  bed  was  dark,  some- 
what rough  and  without  any  secretion  or  debris  in  its  cavity,  and  it  re- 
quired no  mopping. 

Malignancy.  The  gastroscopic  appearance  of  malignant  neoplasms 
varies  widely,  not  only  in  different  cases  but  in-  different  portions  of  the 
same  lesion.  In  all  that  have  been  observed,  however,  there  is  marked 
contrast  with  the  normal  mucosa  that  is  very  striking.  Not  only  the  nor- 
mal folds  are  gone,  but  the  surface  of  the  lesion  is  irregular  and  granular 
or  nodular.  In  most  instances  it  was  covered  with  secretion  varying  in 
color  from  white  through  gray  and  yellow  to  pink,  red,  crimson,  purple 
and  brown. 

The  secretion  is  sometimes  mottled  with  brown  flakes. 

In  the  first  two  cases  examined  (Figures  14  and  15,  Plate  IV),  the 
author  hesitated  to  remove  this  secretion  lest  hemorrhage  be  started.  In 
the  later  cases,  however,  it  was  found  that  wiping  away  the  secretion 
gently  did  not  produce  hemorrhage,  and  a  better  view  of  the  colors  of  the 
lesions  themselves  was  thus  obtained. 

These  colors  vary  widely  not  only  in  different  lesions  but  in  different 
parts  of  the  same  lesion.  In  one  case  the  color  varied  in  ditferent  parts 
from  pale  grayish  yellow  to  pink,  deep  red,  crimson,  and  brown,  with  a 
number  of  patches  of  small  brown  and  crimson  points  apparently  where 
hemorrhages  had  occurred.  One  portion  of  this  mass  after  wiping  looked 
like  an  over-ripe  mulberr\-.  This  was  beautifully  shown  at  one  point 
where  a  nodule  of  this  mass  came  out  in  contrast  with  the  normal  pale  red 
mucosa  beyond  (Fig.  18,  Plate  III).  * 

In  one  case  a  portion  of  the  growth  external  to  the  stomach  wall  could 
be  felt,  with  gastroscope  and  probe,  as  a  densely  hard  mass,  yet  the  over- 
lying mucosa  was  normal  as  to  folds  and  color  (Fig.  20,  Plate  V).  In 
another  portion  the  color  was  normal  but  the  folds  were  absent.  In  this 
portion  the  muscular  wall  was  evidently  involved  but  the  mucosa  was  not. 
(Fig.  48,  Plate  V.)  These  points,  I  think,  promise  to  be  of  great  value 
'.n  differential  diagnosis  between  lesions  of  the  gastric  wall  and  lesions  of 
neighboring  tissues  displacing  the  uninvolved  gastric  wall  inward. 

\'essels  were  seen  in  a  number  of  locations  in  two  cases  of  malig- 
nancy, one  of  these  showing  a  well  marked  zone.     (Fig.  17,  Plate  III.) 

T'he  sense  of  touch  as  transmitted  through  the  tube  is  a  remarkablv 


GASTROPTOSIS  AND  GASTRECTASl.l.  163 

efficient  aid  in  the  diagnosis  of  malignancy.  Tn  one  case  (Fig.  34,  Plate 
\j  the  hardness  of  the  mass  shown  to  the  right  in  the  plate  was  diagnos- 
tic, as  was  also  the  mass  shown  to  the  right  in  Fig.  13,  I'late  I\'. 

G astro l^tosis  and  Gastrcctasia.  The  position  of  the  greater  cun'atnre 
is  always  easily  determined,  as  is  also  the  vertical  diameter  of  the  stomach. 

These  data  are,  of  course,  insufficient  to  differentiate  hetwcen  an 
ectatic  and  a  gastroptotic  stomach.  If  we  can  reach  the  pylorus,  the  diag- 
nosis is  clear.  The  position  of  the  lesser  curvature  which  is  the  diag- 
nostic point  and  which  is  difficult  to  determine  clinically,  is  very  readify 
determined  gastroscopically  in  gastroptotic  or  infantile  stomachs.  If  the 
lesser  curvatmx  is  far  from  vertical  its  position  cannot  be  accurately  de- 
termined, as  in  this  case  it  can  be  inspected  by  external  abdominal  manip- 
ulation, which,  of  course,  gives  no  idea  as  to  its  usual  position. 

The  recent  developments  in  Roentgenograph}'  lessen  the  value  of  gas- 
troscopy  in  the  diagnosis  of  anomalies  or  abnormalities  of  position. 
Authorities  state  that  the  lesser  curvatare  is  difficult  to  show,  bv  the 
bismuth  method,  and  the  air,  gas  or  water  methods  cause  displacements ; 
and,  further,  ihat  the  Roentgen  process  is  difficult  in  the  vers-  stout.  If 
these  things  be,  gastroscopy  can  supplement  Roentgenograph}'  in  many 
instances. 


BIBLIOGRAPHY. 


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178  BIBLIOGRAPHY  OF  RSOPHAGOSCOPY. 

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(317)  Rosenheim,    Th.,     Ueber    die    Besichtigung    der    Kardia    nebst 

Bemerkungen  uber  Gastroskopie.  Deutsche  med.  Wochenschr. 
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(318)  Rosenheim,   Th.,    Ueber    die   Neurosen    des   Oesophagus.    Allg. 

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(320)  Rosenheim,    Th.,     Ueber    Oesophagoskopie    und    Gastroskopie. 

Deutsche  med.  Wochenschr.  1896,  Nr.  43,  S.  688. 

(321)  Rosenlieiin,  Th.,    Uber  Gastroskopie  (mit  Demonstration).    Berl. 

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BIBLIOGRAPHY  OF  ESOPHAGOSCOPY.  185 

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BIBLIOGRAPHY  OF  ESOPHAGOSCOPY .  187 

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DESCRIPTION  OF  PLATES. 

Plate  I. 

1.  Tracheal  papilloma.  Girl  of  4  years.  Removed  through  trache- 
oscope.    Referred  by  Dr.  Brush. 

2.  Tracheal  compression  by  struma.  Feeble  pulsatory  excursion. 
Man  of  ^^  years.     Referred  by  Dr.  Heard. 

3.  Tracheal  compression  by  aneurysm.  Violent  pulsatory  excur- 
sion. Dotted  line  shows  limit  of  recession  of  bulging.  Man  of  60  years 
referred  by  Dr.  Price. 

4.  Cicatrical  stenotic  web  in  trachea  resulting  from  ulceration  caused 
by  a  foreign  body  in  the  esophagus.  Child  2  years  of  age.  Referred  by 
Dr.  Ryall." 

5.  Scabbard  trachea.  Thymic  tracheo-stenosis.  Cured  by  thymec- 
tomy.    Child  of  4  years.     Referred  by  Dr.  Boyce. 

6.  Egg  shell  in  edematous  larynx.  In  situ  4  weeks.  Removed  by 
direct  laryngoscopy.  Infant  9  months  of  age.  Referred  by  Dr.  Moyer 
and  Dr.  Wechsler. 

7.  Button  fixed  in  the  trachea  by  the  swollen  mucosa.  Whistling 
respiration.     Boy  of  14  years.     Referred  by  Dr.  Crawford. 

8.  Luetic  tracheal  stenosis.  Man  24  years  of  age.  Referred  by  Dr. 
F.  T.  Smith. 

9.  Compression  stenosis  of  the  trachea  by  an  esophageal  carcinoma. 
Man  aged  60.     Referred  by  Dr.  Sanes. 

Plate  II. 

10.  View  looking  down  left  bronchus.  To  the  left  above  is  the 
opening  of  the  superior  lobe  bronclius.  To'  the  right  the  inferior  lobe 
bronchus. 

11.  Normal  \'iew  looking  down  right  bronchus.  Above  is  the  mid- 
dle lobe  bronchus :  below  to  the  left  the  inferior  lobe  bronchus ;  to  the 
right  the  superior  lobe  bronchus,  appearing  larger  because  nearer. 

12.  Fungating  granulations  from  healing  cartilage,  after  trache- 
otomy.    Skin  allowed  to  unite  per  priiuam. 


DiLSCRirriox  or  plates.  i89 

13.     ]^-in,ary  Irechcal  ozena,     (iirl  aged   ih  years.     Referred  by  Dr. 

Wallace.   ^^^^^^^^^  ^^^^^^  ^^^^^^,^  cicatrices.     Right  bronchus  of  man  aged 

23  years.     Referred  by  Dr.  F.  T.  Smith.  „  ,    ,      ,  .  , 

IS      Compression  stenosis  of  trachea.    Posterior  wall  bulged  forward 

by  tubercular  lymph  nodes.     Woman  aged   25  years.     Referred  by  Dr. 

Schildecker. 

Pi,.\TE  HI. 

1.  Introitus  esophagi.     Normal.     Dark  lino  must  not  be  understood 
as  a  gaping.     Collapsed  shut.     Man  of  36. 

2.  Intra-thoracic   esophagus.      Unusual    view,    but   normal.      More 
usual  appearance  shown  in  Fig.  I..  Plate  I\  .  ... 

3.  Esophagus  at  hiatus  diaphragmatis  normal.    Note  axis  of  lumen. 

^""T"  Gcatricial  esophageal  stenosis.  Pin-hole  lumen.  White  scars. 
Recurrence  of  stenosis  following  ulceration  during  typhoid  fever.  Prim- 
ary lesion,  burned  bv  swallowing  lye  in  childhood  14  years  previously. 
I\l'r  H.  aged  21  years.    Referred  by  Dr.  Stevenson.  _ 

5  Ibid      Bottom  of  diverticulum.     ?>Iucosa  chronically  inflamed. 

6  Tubercular  ulceration  posterior  esophageal  wall,  simulating 
decubitus  ulcer  often  seen  in  typhoid  fever.  Tubercular  lesion  m  this 
location  is  somewhat  rare,  though  still  more  rarely  is  it  diagnosticated 
Incidentally  this  figure  shows  the  introitus  esophagi  when  the  cricoid 
cartilage  is  lifted  bv  the  laryngeal  speculum.    Compare  Fig.  I.,  above. 

7  Carcinoma  of  the  thoracic  esophageal  wall  (left)  covered  with 
normal  mucosa.  Lumen  pushed  to  the  right  and  almost  obliterated.  Man 
aged  60  years,  referred  by  Dr.  Sanes. 

8  Carcinoma,  endo-esophageal.  Woman  of  41  vears,  referred  for 
chronic  nasal  sinus  disease.  Esophageal  symptoms  slight  and  attributed 
to  globus  hystericus. 

9  and  12.  Fibroma  papillare,  attached  by  long  slender  fibrous  ped- 
uncle Disappeared  into  the  esophagus  at  times  after  swallowing.  Fig. 
12  shows  the  attachment  within  the  esophagus  when  the  cricoid  cartilage 
is  moved  forward  (instrument  not  shown).  Removed  through  tubular 
speculum.     ]Man  aged  36  years,  referred  by  Dr.  Heard. 

10.  View  in  thoracic  esophagus  showing  wounds  (above)  made  by 
blind  groping  with  a  coin  extractor  which  did  not  extract.     Boy  of  14 


years. 


II.  Wound  in  esophageal  wall  made  by  a  pin  which  was  afterward 
found  higher  up.    Woman  of  23  years,  referred  by  Dr.  Pool. 

13.  Normal.  "Kink"  of  the  esophagus  at  the  hiatus,  probably  more 
a  preventive  of  regurgitation  than  the  cardia. 


190  DESCRIPTION  OF  PLATES. 

14.  Peri-esophageal  carcinoma  overlaid  with  normal  mucosa,  lumen 
deviated  so  far  to  right  as  to  be  out  of  view.  Diagnosis  upon  hardness 
of  mass,  and  age  of  the  patient.     jNIan  of  60  years,  referred  by  Dr.  Swope. 

15.  Stomach  ulcer  (on  left  side  of  right  fold  in  the  view),  bed 
showing  dark  after  secretions  had  been  wiped  away.  ( )ther  folds  normal. 
Woman  aged  26  years,  sent  by  Dr.  Moss. 

16.  Stomach.  Normal.  Branched  fold.  Dark  crimson  color.  Ex- 
amined one  horn-  after  drinking  milk.     Man  of  32  years. 

17.  Stomach.  Carcinoma.  Zone  of  hyperemia.  ]dan  of  46  years, 
referred  by  Dr.  Walton. 

18.  Stomach.  Same  patient.  Mulbcrry-likc  nudule  at  another  por- 
tion of  growth. 

Pl.vte  IV. 

1.  Thoracic  esophagus.  Expiration.  Xote  lumen  not  entirely 
closed.     Man  aged  40. 

2,  3,  4,  5  and  6.  Normal  stomach.  I'olds  in  various  positions  as 
seen  separating  and  collapsing  ahead  of  the  tube  as  it  is  inserted  and 
withdrawn.  In  Fig.  4  is  shown  a  horseshoe-shaped  position  of  a  fold 
often  seen  near  the  cardia,  usually  to  the  right.  At  times  seen  elsewhere. 
Compare  Figs.  16  and  18,  Plate  V. 

7  and  8.  Stomach.  Normal  wall  of  inferior  curvature  flattened  by 
pressure  of  the  tube  mouth. 

9.  Gastritis.  F'old  in  lower  right  hand  corner  is  cajiped  by  secretion 
sitnulating  ulcer,  before  wiped  away. 

10.  Gastritis.  All  folds  sponged  but  one.  which  shows  thick  tena- 
cious secretion. 

11.  Gastric  nicer  seen  on  edge.  Not  sponged.  Man  aged  32.  Pa- 
tient of  Dr.  Finkelpearl. 

12.  Same  patient.  Scar  after  healing  of  the  ulcer.  Scar  shows 
yellow  bv  engraver's  error ;  it  should  be  grayish,  nearly  white. 

13.  Carcinoma  of  cardia.  Infiltrated  but  not  ulcerated  hard  mass 
to  right  of  view.     Man  38  years.     Referred  by  Dr.  Haworth. 

14.  Same  patient.  Farther  to  right  than  Fig.  13,  on  lesser  curva- 
ture.    Fungating  portion  of  mass. 

15.  Carcinoma  of  pylorus.  Left  bolder  of  the  tumor.  Man  of  44 
years.    Referred  by  Dr.  Haworth. 

16.  Normal  stomach.  Three  cm.  below  the  cardia.  Note  horseshoe- 
shaped  fold  to  the  right.     Maid  of  19  years.     Patient  of  Dr.  Lichty. 

17.  Normal  stomach,  farther  down,  same  patient.  (\'iews  are  never 
twice  alike,  no  form  is  meant  as  t\pical  of  local  it  w) 

18.  Normal  .'■-tomacH.     Four  cm.  from  cardia.     Woman  of  ^t,  years. 


DIISCRH'TIOX  or  f'L.ITF.S.  191 

19.  Normal  stdiiiacli.  W  niiian  ui  19  years.  Showing  diversifie<l 
forms  of  folds. 

20.  Xormal  stomach.  T'-ans verse  trend  of  folds  as  greater  curva- 
ture is  approached.  Folds  are  rarely  seen  as  straight  as  the  central  one  in 
this  view. 

21.  Approaching  the  pyloris.  Gastroptotic  stomach.  (View  proh- 
ably  not  abnormal.)     Woman  of  :ii  years.     Referred  by  Dr.  Dranga. 

22.  Gastroptotic  stomach  (same  patient).    Pyloris  hidden  by  folds. 

23.  Folds  at  fundus  (not  typical). 

24.  Approaching  the  pyloris.  Folds  disturheil  b>-  tube-mouth.  Same 
patient  as  Fig.  21. 

23.     Same  patient,  same  location,  about  one  minute  later. 

26.  Ditto,  about  one  minute  later.  Amiular  folds  of  pyloris  sur- 
rounding prolapsed  duodenal  folds.  Brownish  fluid  was  regurgitated  into 
stomach. 

2/.  Cancerous  ( ?)  infiltration  near  pyloris.  Fluid  exuded  from 
triangular  slit.    Woman  aged  26  years.     Referred  by  Dr.  Montgomery. 

28.  Gastric  ulcer,  filled  with  secretion,  and  seen  on  edge.  Man 
aged  59  years.     Referred  by  Dr.  Goldsmith. 

29.  Same  ulcer  wiped  clean.     Looking  into  bed  of  ulcer. 

30.  Cicatrix  (  ?)  of  stomach,  in  a  man  59  years  of  age  who  had  a 
specific  history. 

31.  Carcinoma  of  esophagus.  Man  of  60  years,  referred  by  Dr. 
Sanes. 

32.  Carcinoma  (  ?)  of  pyloris.  View  not  at,  but  near  the  pyloris 
on  greaer  curvature.  Color  should  be  much  darker.  Woman  aged  26 
years.     Referred  by  Dr.  Montgomery. 

33.  Carcinoma  of  pyloris.  \'iew  at  left  border.  Other  portions  of 
growth  were  spotted  with  dark  brown.  Man  46  years  of  age.  Referred 
by  Dr.  Walton.  Afterward  operated  upon  by  Dr.  MacClelland  and  diag- 
nosis as  to  size,  shape,  position  and  nature  verified. 

34.  Another  ])ortion  of  same  growth.  Mucosa  normal  but  foldless 
and  hard.     (Right  in  view.) 

35.  Cardiospasm.  Abdominal  esophagismus.  Man  aged  59  years. 
Referred  by  Dr.  Goldsmith. 


PLATE  !. 


PLATE  II. 


PLATE  III. 


PLATE  IV. 


PLATE  V. 


APPENDIX, 


l'.)4 


APPENDIX. 


(X, 


h. 


A'on    Kicktni's   ForL*eps   iiiid    Hriininiis'    Broiichosi  opes. 

A.  B,   Forcci)s,   large  aii<l   small,   ailjiistalilo  iu  li'ii^tli. 

('.  A.spi ni  1  or. 

1>.  10.  F.  i;.  II.  Tubes  of  iliffereut  size.s. 

I.   Handle  for  use  ou  tubes  when  iisiui;   (lie  Kjrsleiii   lieaillainii. 

J,  IIaii(llaiH|]  r<ir  jlliiniinaticiu  of  tiihe, 


Appnxnix.  liT) 

W'iiik'  this  honk  was  in  press.  Professor  (lustav  Killian.  upon  a  visit 
to  this  country,  exliihited  the  l)ninch;isco]iic  ttihes  of  llriinini^'s.  These 
consist  essentially  of  a  long  tnlie-spatula  in  which  an  inner  tnhe  tele- 
scopes (  D,  E,  F,  G,  H).  The  itiner  tuhe  has  at  one  side  a  long  ^lenller 
piece  of  coiled  steel,  like  a  watch  spring,  which,  when  the  inner  tube  is 
piislted  in  until  flush  with  tlie  outer  tube,  serves  to  ])ush  the  inner  tube  as 
much  farther  as  desired. 

The  illumination  is  by  a  hand  lamp  (J  )  attached  to  the  outer  end  of 
the  outer  tube,  the  light  mirror  being  thrown  out  of  the  wa\'  when  it  is 
desired  to  introduce  an  aspirator,  cotton  carriers  or  other  instruments.  In 
the  event  of  the  giving  out  of  the  hand  lamp,  the  Kirstein  headlamp  is 
used,  and  may  be  preferred  by  some  operators,  though  the  hand  lamp 
will  be  found  best  for  use  during  introduction  of  the  instruments.  The 
handle  (I)  may  be  used  instead  of  the  hand  lamp,  when  a  headlamp  is 
used  for  illumination. 

In  use.  the  outer  tube  of  tubc-spatular  form  is  inserted  over  the  dor- 
sum of  the  tongue,  posterior  to  the  epiglottis,  and  into  anil  through  the 
glottis  into  the  upper  end  of  the  trachea.  Then  the  inner  telescopic  tube 
is  inserted  into  the  tube-spatula  and  pushed  downward  as  far  as  desired. 

A  forceps  (.\,  P.),  which  also  telescopes  so  as  to  |iermit  of  shorten- 
ing and  lengthening,  was  designed  by  \'on  Eicken. 

At  C  is  shown  an  aspirator,  the  tube  of  which  is  inserted  into  the 
bronchoscope  as  often  as  needed. 


INDEX. 


Page 

Anomalies   of  the   esophagus 105 

Appearances,     normal      esophago- 

scopic lOi 

Bronchi,    anatomy    of 63 

Diaphragm,  esophageal  opening  in.  gS 
Dimensions    of    the    trachea    and 

bronchi 65 

Endoscopic     appearances     of     the 

trachea   and   bronchi 66 

Esophagus,  anatomy  of 97 

Esophagus,  anomalies  of 105 

Esophagus,  dimensions  of 97 

Esophagus,  position  of 99 

Stomach,  size,  shape  and  position 

of 150 

Tracheo-bronchial    tree,    anatnniv 

of 63 

Direct  Laryngoscopy. 

Abscess  of  the  laryn.\ 60 

Benign   neoplasms 59 

Contra-indications  and  dangers  in 

direct   laryngoscopy 54 

Cicatricial  stenoses  of  the  larynx.  60 

Dangers   and   contra-indications..  54 

Difficulties  in  direct  laryngoscopy.  55 

Diseased  conditions 58 

Direct  laryngoscopy  for  diagnosis 

and  treatment 54 

Foreign   bodies   in   the  larynx....  57 

Galvano-cauitery  use  of  in  larynx.  62 
Inflammatory      diseases      of      the 

larynx 60 

Laryngeal  paralyses   61 

Malignant   disease  of  ithe   larynx.  58 

Retrograde    laryngoscopy 6j 

Position    of    the    patient    for    di- 
rect laryngoscopy 146 

Preparation  of  the   patient 3S 

Second  assistant,  duties  of,  in  en- 
doscopy /><»)•  OS 145 

Sensory   laryngeal   neuroses 61 

Tcchnic   39,  42 

Tuberculosis,   laryngeal 60 

Webs  of  the  larynx,  congenital..  62 

LsopH.\r.us. 

Acute    esophagitis    120 

Anomalies  of  the  esophagus 105 


Page 

Anatomy  of  the  esophagus 97 

Appearances,     normal     csophago- 

scopic loi 

Benign   neoplasms  of  the   esopha- 
gus,   treatment    of 113 

Benign  neoplasms   of  the   esopha- 
gus    112 

Bibliography,    esophagoscopy    and 

gastroscopy 176 

Bouginage  per  tubam  in  the  treat- 
ment of  esophageal  stenosis....    108 

Cardiospasm   114 

Cicatricial  stenoses  of  the  esopha- 
gus, treatment  of 107 

Cicatricial  stenoses  of  the  esopha- 
gus     106 

Compression      stenoses      of      the 

esophagus 115 

Contra-indications,    esophagoscopy  155 

Chronic  esophagitis   120 

Dangers   of  esophagoscopy 155 

Diaphragmatis,  hiatus  esophagcus.     96 

Diseases   of  the  esophagus 105 

Difficulties  in  esophagoscopy ..  147,  15s 

Dilatations  of  the  esophagus 118 

Dilatation   of  esophageal  stricture 

with   the  laminaria  tent 109 

Dilatation   of   esophageal   stricture 

with   the   laminaria   tent 109 

Dimensions  of  the  esophagus 97 

Diverticula,    esophageal 117 

Esophagitis,   acute 120 

Esophagitis,    chronic 120 

Esophagitis,   treatment   of 121 

Esophagoscope,  passing  the 144 

Esophagoscopy 96 

Esophagospasm    115 

Examination  of  the  upper  end  of 

the    esophagus 103 

Foreign  bodies  in  the  esophagus..    124 

Hiatus  esophageus 98 

Inflammation  of  the  esophagus...    120 
Inflammatory      diseases      of      the 

esophagus 106 

Malignant   disease  of  the  esopha- 
gus     no 

Malignant   disease   of  the  esopha- 
gus,  treatment  of 1 12 

Movements   of   the   esophagus....     gg 


INDEX. 


107 


PaKe 

XcitroECS   of   the   esophagus 122 

Non-stcnotic      diseases      of      the 

esophagus 117 

Paralyses  of   the  esophagus 122 

Pareses  of  the  esophagus 122 

Passing  the  esophagoscopc 103 

Passing  the  esophagoscope 144 

Phrenospasni    114 

Position  of  the  esophagus 99 

Position  of  the  patient 146 

Safety  pin  in  the  esophagus,  clos- 
ing  a 126 

Second     assistant,     duties     of     in 

endoscopy  f'cr  os 145 

Shock,    question    of,    in    esophgo- 

scopy 156 

Spastic    stenoses    of    the    esopha- 
gus, treatment  of 115 

Stenoses  of  the  esophagus  due  to 

compression it? 

Stenoses  of  the  esophagus,  spastic.  114 
Stenotic    diseases    of    the    esopha- 
gus   106 

Teclinic  of  csophagoscopy 103 

Treatment    of   cicatricial    stenoses 

of   the   esophagus 107 

Treatment    of    malignant    disease 

of  the   esophagus 112 

Ulceration   of  the   esophagus T2i 

Ulceration  of  the  esophagus,  sten- 
osis   following 107 

Gastroscopv. 

Anesthesia  in  gastroscopy 142 

Appearances,  gastroscopic 158 

Area    of    stomach    explorahle    by 

gastroscopy 151 

Bibliography      of      csophagoscopy 

and    gastroscopy 176 

Contra-indications   to  gastroscopy.  155 

Dangers  of  gastroscopy 155 

Dicta,  fundamental,  in  gastroscopy  137 

Difificulties    in    gastroscopy 47,   153 

Explorahle  area  of  the  stomacli..    151 
Foreign  bodies  in  the  stomach,  re- 
moval   of   by   gastroscopy 139 

Gastroptosis    and    gastreotasia.  .  . .   163 

Gastritis 161 

History   of   gastroscopy 130 

Instruments    for   gastroscopy 140 

Jones,  Clement  R.,  method  of  in- 
troducing the  gastroscope 144 

Alalignant  disease  of  the  stomach.  162 
Mikulicz's   work   in   gastroscopy..   132 

Passing    the   gastroscope 144 

Peptic    ulcer 161 

Position  of  the  patient  in  gastro- 
scopy     146 

Position  of  the  patient ..  143,    145,  146 

Preparation  of  the  patient 142 

Rosenheim,  work  in  gastroscopy..    133 
Second     assistant,     duties     of     in 
endoscopy  per  os 145 


Pak'c 
Shock,     question     of,     in     gastro- 
scopy   1 56 

Stomach,    area    of    explorahle    l)y 

gastroscopy 151 

Stomach,  determination  of  its  size 

and   position 150,  163 

Stomach,   movements    of,   as    seen 

gastroscopically 159 

Technic   of   gastroscopy 142 

Usefulness  of  gastroscopy 13S 

IIlSTORIC.XL    \OTF.S. 

Bozini,  Vol'talini,  Waldenberg, 
Stocrck,  Kussmaul,  Trouve, 
Mikulicz,  Gottstein,  Von  .\cker, 
Kirstein,  Killian,  Coolidge,  Von 

Schroetter,    Piniazek 13 

Einhorn,   Guisez,   Ingals,  Jackson.  14 

Gastroscopy,   history   of 130 

Mikulicz's,  work  in  gastroscopy..  132 
Xitze,  attempt  to  construct  a  gas- 
troscope   130 

Rcwidzof,    work   in   gastroscopy..  135 

Rosenheim's  work  in  gastroscopy.  133 

Instruments. 

Aspirator,  Killian   192 

Aspirator,  Jackson   25 

Battery,  bronchoscopic,  Jackson..  30 

Bougie,    Bunt,   esophageal 108 

Bronchoscope,    Briinings 192 

Bronchoscopes',  sizes  of 31 

Bronchoscopes,    selection    of   sizes 

for  particular  case 51 

Bronchoscope,    Jackson 24 

Bronchoscope,    Ingals 24 

Bronchoscope,   Von    Schroetter...  23 

Bronchoscope,    Killian 22 

Bunt,   esophageal   bougie 108 

Briinings,  bronchoscope    192 

Casper,    electroscope    16 

Coolidge,  cotton  carrier 28 

Coolidge,   forceps    25 

Cotton   carrier,   Coolidge 28 

Cotton    carriers,    Mikulicz 28 

Von    Eicken,    forceps 192 

Einhorn,    Esophagoscope 23 

Electrode,  laryngeal   61 

Electrode,  galvano-cautery    62 

Electroscope,   Casper 16 

Esopliagoscope,    Jackson 24 

Esophagoscope,    Einhorn 23 

Esophagoscope,  fenestrated,  Kir- 
stein    22 

Esophagoscope,  Starck    21 

Esophagoscope,  Von  Hacker 21 

Esophagoscope,  Rosenheim 20 

Esophagoscope,  Mikulicz 20 

Ferguson,  mouth  ga.g 29 

Forceps,  cotton  holding  laryngeal, 

Sajous .'.  .' 39 

Forceps,    Coolidge '2^ 

Forceps,   Von   Eicken 192 


198 


INDEX. 


Page 

Forceps,    Jackson 27 

Forceps,    Killian 27 

Gag,    Ferguson 29 

Gastroscopy,  instruments  for....  140 

Gastroscope.   Jackson 24,  140 

Gastroscope,    Mikulicz 131 

Gostroscope,   Rewidzof 135 

Gastroscope,    Rosenheim 133 

Gastroscope.   Trouve 130 

Guisez,  headlamp    15 

Von  Hacker,  esophagoscope 21 

Headlamp,   Guisez 15 

Headlamp,   Kirstein 15 

Hooks 28 

Ingals,    Bronchoscope 24 

Instruments,  list  of 31 

Jackson,   bronchoscope    24 

Jackson,  esophagoscope  24 

Jackson,    forceps 27 

Jackson,   gastroscope    24,  140 

Jackson,   laryngeal   knife 2g 

Jackson,  safety  pin  closer 28 

Jackson,    secretion    aspirator 25 

Jackson    separable    speculum 19 

Jackson,  tent  carrier 28 

Jackson    tubular    speculum ig 

Jones,  Clement,  sound  for  the  in- 
troduction  of  the  gastroscope..  141 

Killian.    aspirator 192 

Killian,   bronchoscope    22 

Killian,   forceps 27 

Killian,    split    tubular    spaitula....  17 

Killian,    tubular    spatula 17 

Kirstein,      esophagoscope,      fenes- 
trated   22 

Kirstein,    headlamp    15 

Knife,   laryngeal,   Jackson 29 

Manikin,    Killian 35 

Mikulicz,  cotton  carrier 2-! 

^Mikulicz,    esophagoscope    20 

Mikulicz,    gastroscope 13' 

Mosher,  esophageal  instrument...  18 

Mosher,   esophageal   speculum....  18 

Mosher,  safety  pin  closer 2-! 

Mouth  gag.  Ferguson 29 

Rewidzof,   gastroscope 135 

Rosenheim,  esophagoscope  20 

Rosenheim,   gastroscope 133 

Safety  pin  closer,   Jackson 28 

Safety  pin  closer,  Mosher 28 

Sojous_,   cotton-holding   forceps...  39 
Von    Schroetter,    bronchoscope...  22, 
Sound,   Clement  Jones,   for  intro- 
ducing the  gastroscope 141 

Starck.   esophagoscope 21 

Speculum.      Jackson's,      separable 

tubular 19 

Speculum.    Mosher's   esophageal..  18 

Spatula,   split,   tubular.   Killian's..  17 

Spectdum.  tubular.  Jackson's 19 

Spatula,  tubular.  Killian's 17 

Tent  carrier.  Jackson 28 

Trouve.    polyscope 130 


Paire 

Tfchnic. 

Acquiring    skill 33 

Adjusting  the   Kirstein   headlamp.  43 

Anesthesia   in   bronchoscopy 47 

Anesthesia  in  direct  laryngoscopy.  39 

■Anesthesia    in    gastroscopy 142 

Asepsis 37 

Bronchoscopy,  anesthesia  in 47 

Bronchoscopy,  lower,  dorsal  decu- 
bitus   50 

Bronchoscopy,   lower,    patient   sit- 
ting   45 

Bronchoscope,   passing   the 47 

Bronchoscope,   passing   the 53 

Bouginage   per   tubam   in   esopha- 
geal   stenosis 109 

Bronchoscopy,    upper 43 

Bronchoscopy,    upper 45 

Cauterization   laryngeal 62 

Dilatation   of  esophageal   stenosis. 

instrumental 109 

Diltation    of   esophageal   stricture. 

instrumental 109 

Direct  laryngoscopy,  anesthesia  in.  39 
Direct    laryngoscopy,    diagram    of 

position   in   operating-room 41 

Direct  laryngoscopy,   dorsal  decu- 
bitus   45 

Direct    laryngoscopy,    patient    sit- 
ting   40 

Dog,  as  an  animal  subject 35 

Esophagoscopy,  technic  of 103 

Foreign    body,    tracheo-bronchos- 

copy    for 92 

Gastroscope,     Clement     R.     Jones 

method  of  introduction  of  the..  144 

Gastroscope,   introduction    of  the.  144 

Gastroscopy.   anesthesia   in 142 

Gastroscopy.   technic  of 142 

Jones.  Clement  R.,  method  of  in- 
troducing the  gastroscope 144 

Killian.  manikin    35 

Kirstein   headlamp,   adjusting   the.  49 

Laryngeal  speculum,  use  of 42 

Laryngoscopy,    direct,    dorsal    de- 
cubitus   45 

Laryngoscopy,    retrograde 62 

Lower    tracheobronchoscopy 45 

Operating"    room    arrangement....  41 

Operating    room   arrangement....  46 

Passing  the  bronchoscope 47 

Passing  the  bronchoscope -.  . .  S3 

Patient,  preparation  of 38 

Position  of  patient  in  direct  laryn- 
goscopy,     tracheo-bronclioscopy 

esophagoscopy  and  gastroscopy.  146 

Preparation   of  patient 38 

Preparation  of  the  patient  for  gas- 
troscopy    142 

Safety  pin  closer,  use  of 126 

Second  assistant,  duties  of.  in  en- 
doscopy per  OS 145 

Sterilization     },'/ 


lADJzX. 


I'.iit 


Page 

Tracheo-broiichoscopy  for  for- 
eign   liody 9- 

Traciieo-bronchoscopy,  lower,  dor- 
sal   deculMtus 50 

Tracheo-bronchoscopy.  lower,  pa- 
tient  sitting 45 

Tracheo-bronchoscopy,  upper 4,? 

Tracheo-bronchoscopy,  upper 45 

Tracheotomy 5t 

Upper   tracheo-bronchoscopy 4,1 

Trachea  and  Bronchi. 

Anatomy  of  the  trachea  and 
bronchi 64 

Aneurysm  as  a  cause  of  traclieal 
stenosis 7,? 

Asthma   thymicuin    70 

Benign    neoplasms    nuiro-tracbcal.     73 

Bibliography  of  tracheo-broncho- 
scopy     164 

Boyce,  physical  signs  of  foreign 
body  in  the  air  passages 90 

Bronchoscopy,  upper  and  lower, 
rehuive  advisability  of 80 

Cicatricial  stenosis  of  the  trachea 
from   foreign  body "5 

Contra-indications  to  traclieo- 
bronchoscopy  in  foreign  body 
cases    8j 

Dangers  of  tracheo-bronchoscopy 
in  foreign  body  cases 82 

Deviation  of  the  trachea 77 

Diagnosis  of  foreign  body  in  the 
trachea   and   bronchi 86 

Dimensions  of  the  trachea  and 
bronchi 65 

Diseas'es  of  the  trachea  and  bron- 
chi,  non-stenotic 63 

Diseases  of  the  trachea  and  bron- 
chi,  tracheo-bronchoscopy   in...     68 

Endoscopic  appearances  of  the 
trachea   and   bronchi 66 

Extraction  of  foreign  bodies 92 

Foreign  body  cases,  dangers  of 
traceo-bronchoscopy    in 82 

Foreign  body,  dangers  of  not  re- 
moving      8,^ 

Foreign  body,  diagnosis  of 86 

Foreign  bodies  in  the  trachea 
and    bronchi 80 

Foreign  Ijodies  in  the  trachea  and 
bronchi,  indications  for  tracheo- 
bronchoscopy   , 81 


Page 

Foreign  bodies,  results  of  tracheo- 
bronchoscopy   in   the   extraction 

of 81 

Foreign  body,  symptoms  of 85 

Glanders     of     the     tracliea     and 

bronchi 7.? 

Indications     for    tracheo-broncho- 
scopy in  foreign  body  cases....     81 
Inflammations  of  the  trachea  and 

bronchi 7,? 

Malignant        neoplasms,        muro- 

tracheal    73 

Non-stenotic      diseases      of      the 

trachea  and  bronchi 68 

Physical  signs  in  diagnosis  of  for- 
eign body 93 

Position   of   the   patient 146 

Stenoses    of   the   tracliea 75 

Stricture   of   the   trachea 75 

Retrograde  laryngoscopy 62 

Roentgen  ray,  in  the  diagnosis  of 

foreign   l>ody    86 

Second  assistant,  duties  of,  in  en- 
doscopy per  OS 145 

Specific      inflammations      of      the 

trachea   and   bronchi 7.3 

Stenoses    of   the   trachea 69 

Stenosis     of     the     trachea     from 

muro-tracheal   conditions 7,; 

Symptoius  of  foreign  body  in  the 

trachea   and  bronchi 86 

Svphilis  of  the  trachea  and  liron 

'chi 7.? 

Technic   of   extraction   of    foreign 

liodies 92 

Thymic   asthma    70 

Thymic   tracheo-stenosis    70 

Tracheo-bronchoscopy,     contra-in- 
dications in   foreign  body  cases.     82 
Tracheo-bronchoscopy   in   diseases 
of  the  trachea   and  Ijronchi ....     68 

Trachea,  stenoses  of 69 

Tracheal   stenoses,   treatment  of..     77 

Tracheotomy    51 

Treatment   of   tracheal   stenoses..     77 

Tumors,   mediastinal    70 

Tumors,  peritracheal  70 

Tuberculosis    of    the    trachea    and 

bronchi   7,? 

Typhoid     fever,     inflammation     of 

the  trachea   in 75 

Ulcerations    of    the    trachea    and 
bronchi   7,5 


1 


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